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 B
Explanation
The correct answer is Choice B: Speak in a normal voice at a natural pace.
Choice A rationale: Directing statements to the interpreter is inappropriate because it can make the client feel excluded from the conversation. The focus of communication should be on the client, and the interpreter is present only to facilitate understanding between the nurse and the client. Direct eye contact and addressing the client directly is important for establishing rapport and trust.
Choice B rationale: Speaking in a normal voice at a natural pace is crucial when working with an interpreter to ensure accurate translation and comprehension. It provides the interpreter with enough time to accurately convey the message while maintaining a conversational flow. Speaking too fast or in an unnatural tone can create confusion and lead to misinterpretation, ultimately affecting the quality of care provided to the client.
Choice C rationale: Using gestures while speaking with the client may not be helpful when working with an interpreter. Gestures may be culturally specific and can lead to misunderstandings or misinterpretations. Furthermore, the interpreter may not be able to accurately convey the intended message through gestures, leading to communication errors.
Choice D rationale: Pausing in the middle of sentences is not recommended when working with an interpreter. This practice can disrupt the flow of the conversation, confuse the interpreter, and lead to incomplete translations. It is essential to speak in complete sentences and provide pauses between sentences to enable the interpreter to accurately translate the information to the client.
Correct Answer is C
Explanation
The correct answer is choice C: Initiate continuous cardiac monitoring.
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.
Choice B rationale:
Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.
Choice C rationale:
Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.