A nurse is providing discharge teaching to a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching?

"Place cellular phones on the ear opposite the side of the pacemaker.".

"Avoid showering for the first 2 weeks following surgery.".

"Avoid heavy lifting for 1 week following insertion.".

"Stand at least 2 feet away while using a microwave.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:
The nurse should instruct the client to place cellular phones on the ear opposite the side of the pacemaker to minimize the risk of electromagnetic interference. Although the risk of interference is low with modern pacemakers, it is still a precautionary measure. Placing the phone on the ear opposite the pacemaker reduces the likelihood of any potential electromagnetic interaction.
Choice B rationale:
The instruction in choice B, "Avoid showering for the first 2 weeks following surgery,”. is not appropriate. There is no need for the client to avoid showering after pacemaker insertion. In fact, maintaining good hygiene is essential to prevent infection at the incision site. The client can take a shower, but they should avoid soaking the incision area and patting it dry afterward.
Choice C rationale:
The instruction in choice C, "Avoid heavy lifting for 1 week following insertion,”. is not the best option. The recommended timeframe to avoid heavy lifting after a pacemaker insertion is usually around 4 to 6 weeks. This duration allows the surgical site to heal properly and reduces the risk of dislodging the pacemaker leads or causing damage.
Choice D rationale:
The instruction in choice D, "Stand at least 2 feet away while using a microwave,”. is not directly related to pacemaker care. While it is generally recommended to maintain a safe distance from microwaves during use, this instruction is not specific to clients with pacemakers.

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Correct Answer is A

Explanation

Dispose of the client's feces and urine in a special container.

Choice A rationale:

This is the correct choice. Brachytherapy involves the placement of a radiation source in or near the tumor. To minimize radiation exposure to others, the client's bodily fluids (feces and urine) should be considered radioactive and disposed of properly in a designated container.

Choice B rationale:

While limiting the time of visitors can be a good measure to reduce radiation exposure, it is not the priority intervention. The primary concern is proper handling and disposal of radioactive bodily fluids.

Choice C rationale:

Keeping the client's linens in the room until after removal of the radiation source is not the correct choice. Radioactive linens should be handled and laundered separately, following appropriate safety protocols.

Choice D rationale:

Providing one dosimeter badge for staff to share while caring for the client is not adequate. Each staff member involved in direct care should have their dosimeter badge to monitor their individual radiation exposure levels.

A. WBC 11,000/mm² in a client who is starting treatment for a methicillin-resistant staphylococcus aureus (MRSA) infection. B. Serum pH 7.25 in a client who has type 1 diabetes mellitus. C. Hematocrit 26% in a client who has sickle cell disease. D. Urine specific gravity 1.032 in a client who is diagnosed with dehydration.

Correct Answer is B

Explanation

Choice A rationale:
An elevated WBC count (11,000/mm²) in a client starting treatment for MRSA infection may indicate an inflammatory response, but it is expected in this scenario, and the priority is not as high as other critical lab values.
Choice B rationale:
A serum pH of 7.25 indicates acidosis, which is a potentially life-threatening condition. In type 1 diabetes mellitus, diabetic ketoacidosis (DKA) is a common complication that can lead to metabolic acidosis. This lab result is a priority as it requires immediate attention.
Choice C rationale:
Hematocrit of 26% in a client with sickle cell disease might be low, but it is not the priority over the critically abnormal lab value of serum pH in option B.
Choice D rationale:
A urine specific gravity of 1.032 in a client diagnosed with dehydration is elevated, indicating concentrated urine due to dehydration. While dehydration is concerning, it is not as high-priority as the potentially life-threatening acidosis in option B.

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A nurse is providing discharge teaching to a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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