A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

Physical therapy

Serum cardiac enzyme levels

MRI of the chest

Low sodium diet

Answer and Explanation

The Correct Answer is C

Choice A reason: Physical therapy may be prescribed postoperatively to aid in recovery, but it does not directly interfere with the function of a pacemaker.

Choice B reason: Checking serum cardiac enzyme levels is a common practice after heart surgery to assess for any damage to the heart muscle, which would not typically require clarification in the context of pacemaker insertion.

Choice C reason: An MRI of the chest should be clarified with the healthcare provider because MRI can interfere with pacemaker function. Patients with pacemakers are generally advised to avoid MRI unless the pacemaker is Incompatible, due to the risk of the magnetic field affecting the device's operation.

Choice D reason: A low sodium diet may be recommended for patients with heart conditions to manage blood pressure and fluid retention, but it is not directly related to the care of a pacemaker.

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Correct Answer is C

Explanation

Choice A reason: The blood should not be infusing for 5 hours as transfusions of packed RBCs should be completed within 2 to 4 hours to minimize the risk of bacterial growth and transfusion reactions.

Choice B reason: Medications should not be administered through the same IV line as blood products due to the risk of reactions and interactions.

Choice C reason: The packed RBCs are indeed connected by Tubing to normal saline, which is used to keep the line open and prevent clotting.

Choice D reason: The drip chamber should not be filled completely with blood as it is necessary to monitor the drip rate and to ensure that air does not enter the line.

A. Prepare to administer a vasopressor. B. Administer an anticholinesterase medication. C. Prepare the client for intubation. D. Instruct the client to perform pursed lip breathing.

Correct Answer is C

Explanation

The correct answer is: c. Prepare the client for intubation.

Choice A: Prepare to administer a vasopressor

Reason: Vasopressors are typically used to manage hypotension (low blood pressure) and are not a standard treatment for myasthenic crisis. Myasthenic crisis primarily involves respiratory muscle weakness, which can lead to respiratory failure, rather than issues with blood pressure.

Choice B: Administer an anticholinesterase medication

Reason: While anticholinesterase medications like pyridostigmine are used to manage myasthenia gravis, they are generally not recommended during a myasthenic crisis. During a crisis, the focus is on stabilizing the patient, often requiring more immediate interventions such as intubation and mechanical ventilation.

Choice C: Prepare the client for intubation

Reason: Intubation is a critical intervention in a myasthenic crisis due to the risk of respiratory failure. The crisis is characterized by severe muscle weakness, including the muscles that control breathing. Intubation ensures that the airway is protected and that the patient can receive adequate ventilation.

Choice D: Instruct the client to perform pursed lip breathing

Reason: Pursed lip breathing is a technique used to improve breathing efficiency in conditions like chronic obstructive pulmonary disease (COPD). However, it is not appropriate for managing a myasthenic crisis, where the primary issue is severe muscle weakness leading to respiratory failure.

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A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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