A nurse is providing teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

"I will hold my cellphone on the opposite side of the pacemaker."

"I can resume physical activity within 2 weeks."

"I need to cover my pacemaker with a dressing when I shower."

"I should avoid using a microwave oven."

Answer and Explanation

The Correct Answer is A

A. "I will hold my cellphone on the opposite side of the pacemaker.": Cellphones emit electromagnetic signals that can interfere with pacemaker function if held directly over the device. Keeping the phone on the opposite side minimizes the risk of interference and ensures proper pacemaker function.

B. "I can resume physical activity within 2 weeks.": Strenuous physical activity should be avoided for about 4-6 weeks to allow proper healing of the pacemaker site. Early resumption of activity can lead to lead dislodgement or complications.

C. "I need to cover my pacemaker with a dressing when I shower.": After the initial post-procedure period, there is no need to keep the pacemaker site covered while showering. The incision should be kept dry until it fully heals, but a permanent dressing is unnecessary.

D. "I should avoid using a microwave oven.": Modern pacemakers are shielded against microwave interference, making it safe to use a microwave. This is a common misconception, as older pacemakers were more susceptible to electrical interference.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The first action the nurse should take is assess for dizziness when standing followed by increase dietary iron intake.

Rationale:

Assess for dizziness when standing: The client’s orthostatic hypotension (BP drops from 132/60 to 102/50 mmHg upon standing) and tachycardia (HR 108/min) suggest possible symptomatic anemia. Evaluating for dizziness ensures client safety and helps determine the severity of anemia-related hypoxia.

Increase dietary iron intake: The client has iron deficiency anemia (low hemoglobin, hematocrit, RBC count, and ferritin). Since they follow a vegan diet, increasing plant-based iron sources (e.g., leafy greens, legumes, fortified cereals) and vitamin C intake can improve iron absorption.

Incorrect:

Administer IV fluids: While anemia can cause orthostatic hypotension, fluid resuscitation is not the first-line intervention unless dehydration is present.

Check for signs of bleeding: The client reports no pain or discomfort, and there is no evidence of active bleeding. Anemia is more likely due to chronic dietary deficiency rather than acute blood loss.

Administer vitamin B12 supplements: The client’s vitamin B12 level is slightly low but not critically deficient. The primary issue is iron deficiency, not pernicious anemia.

A. Hypertension B. 2+ edema C. Tachycardia D. Crackles in lungs

Correct Answer is C

Explanation

A. Hypertension: Elevated blood pressure is not a typical sign of bleeding. In cases of significant blood loss, compensatory mechanisms usually lead to hypotension rather than hypertension due to reduced circulating volume. A hypertensive response may occur due to pain or stress but does not indicate hemorrhage.

B. 2+ edema: Postoperative edema can occur from fluid shifts, inflammation, or IV fluid administration but is not a direct indicator of active bleeding. Bleeding is more likely to cause signs of hypovolemia, such as tachycardia or hypotension, rather than localized swelling.

C. Tachycardia: A common early sign of bleeding, as the body compensates for decreased blood volume by increasing heart rate to maintain oxygen delivery. Persistent tachycardia in a postoperative client should raise suspicion for internal bleeding, especially if accompanied by hypotension or pallor.

D. Crackles in lungs: Crackles are usually linked to fluid overload, pneumonia, or heart failure rather than bleeding. Pulmonary congestion may develop after aggressive IV fluid resuscitation, but bleeding primarily manifests with hemodynamic instability rather than respiratory symptoms.

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A nurse is providing teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client. Complete the following sentence by using the lists of options. The first action the nurse should take is ____ followed by _____ .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

Correct Answer is C

Explanation

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