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.".
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This statement indicates the client's fear and concern about the colostomy's odor, showing a lack of adaptation to the situation.
Choice B rationale:
Comparing the stoma to a strawberry with a hole in it might suggest the client is not fully accepting or understanding the colostomy, indicating a lack of adaptation.
Choice C rationale:
This statement suggests that the client has delegated the task of emptying the colostomy bag to their partner, which indicates a level of acceptance and adaptation to the new situation.
The client trusts their partner with this intimate task, demonstrating a positive sign of adaptation.
Choice D rationale:
Eliminating many foods from the diet suggests difficulty in adjusting to the dietary changes required for managing a colostomy, indicating a lack of full adaptation.
Correct Answer is D
Explanation
Choice A rationale:
Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.
Choice B rationale:
Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.
Choice C rationale:
Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.
Choice D rationale:
This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.
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