A nurse is planning educational materials for a client who has a new pacemaker.
Which of the following information should the nurse include?

"Keep mobile phones 4 inches from the pacemaker generator.”

"Limit strenuous physical activity for 8 weeks.”

"Check your pulse rate for 30 seconds at different times throughout the day.”

"Expect to have intermittent, prolonged hiccups.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should include the information about keeping mobile phones at least 4 inches away from the pacemaker generator in the educational materials for the client. This is because mobile phones emit electromagnetic signals that could interfere with the functioning of the pacemaker. Maintaining a safe distance helps prevent electromagnetic interference, ensuring the pacemaker functions properly without any disruptions. It's crucial for the client to be aware of this to prevent potential complications and ensure the pacemaker's effectiveness.

Choice B rationale:

Limiting strenuous physical activity for 8 weeks is not a necessary precaution for a client with a new pacemaker unless specifically advised by the healthcare provider. Patients with pacemakers are often encouraged to resume normal activities after the procedure, with the understanding that they should listen to their bodies and avoid activities that cause discomfort or strain. There is no standard guideline suggesting an 8-week restriction on strenuous physical activity for all patients with new pacemakers.

Choice C rationale:

Checking the pulse rate for 30 seconds at different times throughout the day is a general health practice and not specifically related to the presence of a pacemaker. While monitoring heart rate is essential for overall health, it is not a pacemaker-specific guideline that must be included in the educational materials for a client with a new pacemaker.

Choice D rationale:

Expecting to have intermittent, prolonged hiccups is not relevant information for a client with a new pacemaker. Hiccups are a common physiological phenomenon and are not influenced by the presence of a pacemaker. Including this information in the educational materials would be irrelevant and potentially confusing for the client.

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Correct Answer is ["B","C","E","F"]

Explanation

A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
E. Pain level is 6 on a scale of 0 to 10.The client received morphine as prescribed at 1815, and the pain level is still significant. This isa finding that needs to be reported to the provider
F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.

A. Avoid including raw fruits in the client's diet. B. Restrict visits from young children to 2 hr per day. C. Measure the client's temperature once per shift. D. Use disposable gloves from a box outside the client's room.

Correct Answer is A

Explanation

- A. The nurse should discourage raw fruits due to risk of infection.

- B. There is no standard recommendation against exposure to young children.

- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.

- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.

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A nurse is planning educational materials for a client who has a new pacemaker.Which of the following information should the nurse include?

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Correct Answer is ["B","C","E","F"]

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A nurse is planning educational materials for a client who has a new pacemaker.
Which of the following information should the nurse include?