A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Rationale:

A. "Check your pulse rate for 30 seconds at different times throughout the day.": Clients with pacemakers should check their pulse daily at the same time and for a full minute to ensure the pacemaker is functioning properly. Shorter durations and inconsistent timing may lead to inaccurate assessments.

B. "Limit strenuous physical activity for 8 weeks.” Limiting physical activity, especially involving the upper body, is essential to allow the pacemaker leads to secure in the myocardium. Strain or vigorous movement during the healing phase can displace the leads or disrupt healing.

C. "Remain at least 3 feet away when watching television”: Modern televisions do not emit electromagnetic interference that would affect pacemaker function. There is no need for such distancing, making this instruction inaccurate and unnecessarily restrictive.

D. "Expect to have intermittent, prolonged hiccups.” Persistent hiccups could indicate pacemaker lead displacement or diaphragmatic stimulation and should be reported immediately. They are not an expected or normal finding after pacemaker implantation.

Rationale:

A. Place the oxygen tank away from curtains or drapes: Oxygen supports combustion, so tanks must be kept away from flammable materials such as curtains or drapes. This placement reduces fire risk and ensures safe home oxygen use.

B. Store the oxygen tank wrench in a locked cabinet: The tank wrench should remain attached to or easily accessible near the tank for emergency shut-off. Locking it away could delay quick responses during equipment malfunction or fire hazards.

C. Ensure that the client checks the gauge weekly: Oxygen tank levels should be checked daily to prevent running out unexpectedly. Waiting a week between checks increases the risk of the tank depleting before a refill is arranged.

D. Have the client store smaller tanks under his bed: Storing tanks under the bed poses a fire hazard due to limited ventilation and proximity to bedding. Oxygen tanks should be stored upright in a secure, well-ventilated area away from heat sources.