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 C

Explanation

Choice A rationale:

Taking colesevelam on an empty stomach is not necessary. This medication can be taken with food to reduce gastrointestinal side effects.

Choice B rationale:

Increasing fiber in the diet is generally beneficial for bowel health, but it is not specific to the use of colesevelam powder for oral suspension.

Choice C rationale:

This is the correct answer because if the oral suspension of colesevelam is cloudy after mixing, it indicates that the medication may have degraded or is not suitable for consumption. Discarding the cloudy suspension ensures that the client receives the appropriate dose and effectiveness of the medication.

Choice D rationale:

Avoiding grapefruit juice is important for some medications, but it is not relevant to colesevelam. Grapefruit juice can interfere with the metabolism of certain drugs, but it does not have a significant effect on colesevelam.

A. Increased peristalsis. B. Abdominal distension. C. Proximal high-pitched bowel sounds. D. Passing flatus.

Correct Answer is B

Explanation

Choice A rationale:

Increased peristalsis would be a positive sign and not indicative of postoperative paralytic ileus. Increased peristalsis would mean the bowel is functioning well.

Choice B rationale:

Abdominal distension is a classic sign of postoperative paralytic ileus, where the bowel's motility is reduced or absent. This condition can lead to a buildup of gas and fluids, causing the abdomen to become distended.

Choice C rationale:

Proximal high-pitched bowel sounds can be a normal finding after surgery, but they are not indicative of paralytic ileus. They may even be heard as the bowel recovers its motility.

Choice D rationale:

Passing flatus is a positive sign, as it indicates that the bowel is working and the patient is passing gas. This is not indicative of a postoperative paralytic ileus, which is characterized by the absence of bowel movement.

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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

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for colesevelam powder for oral suspension. The nurse should include which of the following instructions?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse should identify that which of the following findings indicates that the client has developed a postoperative paralytic ileus?

Correct Answer is B

Explanation

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