A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply)

Do not have a microwave oven in the home.

Request to be scanned with a handheld metal detector when in the airport.

Count your pulse for 1 min each morning.

Do not wear tight clothing over the insertion area.

Resume activities that can cause jolting, such as horseback riding, after 4 weeks.

Answer and Explanation

Correct Answer : C,D

A. Modern pacemakers are designed to withstand interference from microwave ovens, so it is not necessary to avoid having them in the home.
B. Airport security staff should be informed about the pacemaker, but handheld metal detectors should be avoided because prolonged exposure can interfere with pacemaker function. Instead, the client should request a manual search.
C. Monitoring the pulse daily helps to ensure the pacemaker is functioning properly and to detect any irregularities early.
D. Wearing tight clothing over the insertion area can cause discomfort and may interfere with the function of the pacemaker.
E. Activities that involve jolting or the risk of impact to the pacemaker should be avoided until cleared by a healthcare provider, and this period may extend beyond 4 weeks.

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Correct Answer is ["A","B","D"]

Explanation

Decreased Lung Sounds: Could indicate complications such as pneumothorax.

Heart Rate 110/min: Tachycardia may suggest a reaction to recent procedures or other underlying issues.

Subcutaneous Emphysema: Indicates possible air leakage that needs to be addressed.

Does Not Require Immediate Follow-Up:

Oxygen Saturation of 95%: Indicates acceptable oxygenation status.

Trachea Midline: Shows that there is no mediastinal shift.

Puncture Site Dry: Indicates that there is no ongoing issue at the insertion site

A. "Wear an eye patch on the right eye at all times." B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. "Implement a schedule to include periods of rest."

Correct Answer is D

Explanation

A. "Wear an eye patch on the right eye at all times.": This is not appropriate as wearing an eye patch continuously can cause strain on the other eye. It is generally recommended to alternate the eye patch between eyes to manage diplopia (double vision).
B. "Plan to relax in a hot tub spa each day.": This is inappropriate as heat can exacerbate MS symptoms, leading to increased fatigue and other symptoms.
C. "Engage in a vigorous exercise program.": This is inappropriate because vigorous exercise can cause excessive fatigue in individuals with MS. A moderate, well-balanced exercise program is more beneficial.
D. "Implement a schedule to include periods of rest.": This is appropriate as incorporating periods of rest helps manage fatigue, which is a common symptom in MS. It allows the client to balance activity and rest to avoid exacerbation of symptoms.

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A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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