A nurse is planning teaching for a client who has a newly implanted implantable cardioverter-defibrillator.
Which of the following information should the nurse include?
Expect to have a rapid pulse rate for the first few weeks.
Return in two weeks for a follow-up MRI.
Resume tub baths and swimming after 24 hr.
Wear loose-fitting clothing.
The Correct Answer is D
Choice A rationale:
Expecting to have a rapid pulse rate for the first few weeks is not accurate information for a client with a newly implanted implantable cardioverter-defibrillator (ICD). After the ICD placement, the client's heart rate should stabilize within normal ranges. A consistently rapid pulse rate might indicate an issue with the device or the client's cardiovascular system, necessitating further evaluation.
Choice B rationale:
Returning in two weeks for a follow-up MRI is not advisable immediately after ICD placement. MRI (Magnetic Resonance Imaging) is contraindicated for individuals with ICDs due to the magnetic fields, which can interfere with the functioning of the device. The timing and necessity of any future MRI should be carefully planned and discussed with the healthcare provider in charge of the client's care.
Choice C rationale:
Resuming tub baths and swimming after 24 hours is not recommended after ICD placement. Submerging the ICD site in water, especially in the initial healing phase, can increase the risk of infection. Clients with newly implanted ICDs are usually advised to avoid submerging the device site in water for a specified period, as recommended by their healthcare provider.
Choice D rationale:
Wearing loose-fitting clothing is important advice for clients with newly implanted ICDs. Tight clothing, especially around the site of the device, can cause irritation and discomfort. Loose-fitting clothing ensures proper airflow to the site, reducing the risk of irritation and allowing for optimal healing. It is essential to provide this information to the client to promote comfort and prevent complications related to the ICD placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the assistive personnel (AP) to report the client who has a prescription for compression stockings but did not receive them. This situation involves a missed intervention that is crucial for the client's health and safety. Reporting this to the nurse allows timely intervention and ensures that the client receives the necessary care.
Choice B rationale:
Consuming all the food from the meal tray is not a cause for concern and does not require immediate reporting to the nurse. It is a normal behavior and does not indicate any potential issues with the client's health or safety.
Choice C rationale:
The client's request to sit in the bedside chair while watching TV is a common and appropriate request. It does not pose any risk to the client's health or safety and does not require immediate reporting to the nurse.
Choice D rationale:
A client requesting assistance to use the bedside commode indicates a need for assistance with a basic activity of daily living. The AP should assist the client with this request as appropriate and does not need to report it to the nurse unless complications or concerns arise during the process.
Correct Answer is C
Explanation
Choice A rationale:
Sun protection is necessary when using self-tanning creams. These products do not provide protection against harmful UV rays. Failure to use sun protection measures, such as sunscreen and protective clothing, can lead to skin damage and increase the risk of skin cancer.
Choice B rationale:
The risk of injury from firearms does not necessarily decrease as children enter adolescence. Adolescents, like any other age group, should be educated about the dangers of firearms and the importance of firearm safety. Access to firearms should be restricted, and proper storage and education about safe handling are essential.
Choice C rationale:
Driving skills can be impaired when friends are present, especially for new and inexperienced drivers. Peer pressure and distractions from friends can lead to risky behaviors and impaired judgment, increasing the risk of accidents. It is crucial to educate adolescents about the importance of focused and responsible driving.
Choice D rationale:
Medroxyprogesterone is a hormonal contraceptive and does not provide protection against gonorrhea or other sexually transmitted infections (STIs). Safe sex practices, including the use of barrier methods such as condoms, are essential in preventing the transmission of STIs.
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