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 D
Explanation
The correct answer is choice d.
Choice A rationale:
Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.
Choice B rationale:
Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.
Choice C rationale:
While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.
Choice D rationale:
Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.
Correct Answer is D
Explanation
Choice A rationale:
Diazepam (Valium) is not the correct choice in this situation. Diazepam is a sedative and muscle relaxant but would not address the respiratory depression caused by hydromorphone. The client's respiratory rate of 10/min indicates a potential opioid overdose, and the appropriate intervention is to administer naloxone to reverse the opioid effects.
Choice B rationale:
Acetaminophen (Tylenol) is not the correct choice in this scenario. Acetaminophen is a pain reliever and fever reducer but would not address the respiratory depression caused by hydromorphone. The priority is to address the respiratory depression promptly with naloxone.
Choice C rationale:
Ibuprofen (Advil) is not the correct choice in this situation. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation but is not appropriate for reversing opioid-induced respiratory depression. Naloxone is the drug of choice to reverse opioid overdose in this case.
Choice D rationale:
Naloxone (Narcan) is the correct choice. Naloxone is an opioid receptor antagonist used to reverse the effects of opioid overdose, including respiratory depression. Given the client's low respiratory rate, naloxone should be administered promptly to counteract the effects of hydromorphone. This is the most appropriate and potentially life-saving intervention for this client.
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