The nurse is caring for a client who has just had a pacemaker inserted. Which action should the nurse include in the initial plan of care?

Apply warm compresses to site of the client's pacemaker insertion

Teach the client to avoid being near any type of household microwave oven

Ambulate the client as soon as possible to evaluate function of pacemaker.

Instruct client to limit movement of arm on side where pacemaker inserted.

Answer and Explanation

The Correct Answer is D

A. Apply warm compresses to site of the client's pacemaker insertion: Heat application is contraindicated as it may increase swelling or risk infection.

B. Teach the client to avoid being near any type of household microwave oven: Modern pacemakers are shielded, so microwaves do not interfere with their function.

C. Ambulate the client as soon as possible to evaluate pacemaker function: While early ambulation is encouraged, pacemaker function is not evaluated through ambulation.

D. Instruct client to limit movement of the arm on side where pacemaker was inserted: Limiting arm movement prevents dislodging the pacemaker leads during the healing phase.

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Correct Answer is D

Explanation

A. Ventricular aneurysm. Ventricular aneurysms are a complication that typically develops weeks or months after an MI.

B. Heart failure. While heart failure is a risk following an MI, it is more of a concern in the longer term after the acute phase.

C. Pulmonary embolism. Pulmonary embolism is not a direct complication of MI and is less common in the immediate post-MI period.

D. Dysrhythmia: Within the first 24 hours following a myocardial infarction, dysrhythmias, particularly ventricular arrhythmias, are common and can be life-threatening. This is the highest risk during the early period after MI.

A. Administer oxygen via nasal cannula B. Administer prescribed pain medications C. Administer NS IV fluid D. Ask the provider for a dopamine prescription

Correct Answer is A

Explanation

A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.

B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.

C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.

D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.

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The nurse is caring for a client who has just had a pacemaker inserted. Which action should the nurse include in the initial plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is A

Explanation

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