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 B

Explanation

Choice A rationale:

A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.

Choice B rationale:

A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.

Choice C rationale:

The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.

Choice D rationale:

Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.

A. The client's bed has a three-prong plug attached to the electrical cord. B. A protective cover is inserted into an unused outlet. C. An IV pump is plugged into an outlet near a sink. D. An electrical cord is coiled and secured to the floor.

Correct Answer is C

Explanation

Choice A rationale:

A three-prong plug attached to the electrical cord of the client's bed is not a safety hazard. It is a standard plug type used in many electrical devices and poses no immediate danger if properly installed.

Choice B rationale:

Inserting a protective cover into an unused outlet is actually a safety measure to prevent electrical accidents. It is not a hazard but a recommended practice.

Choice C rationale:

Plugging an IV pump into an outlet near a sink is a safety hazard. Water and electricity are a dangerous combination, and any spill or leakage around the outlet could lead to electrical shock or damage to the equipment.

Choice D rationale:

Coiling and securing an electrical cord to the floor can be a potential tripping hazard, but it is not as hazardous as having an electrical device near a sink. Tripping hazards can cause falls, while the combination of water and electricity is more likely to cause serious injuries.

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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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