Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Assess the incision site for signs of infection

Apply a sling to the operative arm

Remove the pacemaker leads

Monitor vital signs regularly

Encourage vigorous physical activity

Answer and Explanation

Correct Answer : A,B,D

A.   Assess the incision site for signs of infection - This is an essential nursing intervention after any surgical procedure, including pacemaker insertion, to prevent and detect early signs of infection.
B.   Apply a sling to the operative arm - This helps to limit movement and prevent dislodging of the pacemaker leads, which is important for the healing process.
C.   Remove the pacemaker leads - This is not an appropriate intervention. The pacemaker leads are left in place after insertion to ensure proper function of the pacemaker.
D.   Monitor vital signs regularly - Regular monitoring of vital signs, especially heart rate and rhythm, is important to detect any complications such as arrhythmias after pacemaker insertion.
E.   Encourage vigorous physical activity - Vigorous physical activity should be avoided initially to prevent any strain or potential damage to the pacemaker or leads. Early mobility is important, but it should be gradual and restricted.

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

Explanation

A. A patient with blood type A- can receive A- blood, as it matches both the ABO blood group and Rh factor.
B. A patient with A- blood cannot receive AB blood because the blood type is incompatible in terms of both ABO group and Rh factor. AB blood contains both A and B antigens, which could lead to an immune response in a type A patient.
C. O- blood is a universal donor for all blood types, meaning it does not contain A or B antigens and does not have the Rh factor, so it can be given to an A- patient.
D. As already noted, A- blood is compatible with an A- patient because both the ABO group and Rh factor are the same.
E. O+ blood contains the Rh antigen, and since the patient is A-, they cannot receive Rh-positive blood, as this could cause an immune reaction.

A. "A wire is in the left ventricle and will pace when needed." B. "There are pacemaker wires in the right atrium and ventricle and will pace as needed." C. "The wires are in both ventricles and fires when your heart rate is 50. D. "The device is set to fire with each heart beat."

Correct Answer is B

Explanation

A. The pacemaker wire for a DDD device is placed in the right atrium and right ventricle, not the left ventricle.
B. This is the correct description of a DDD pacemaker, which has wires in both the right atrium and right ventricle to monitor and pace both chambers when needed.
C. This is incorrect because a DDD pacemaker does not pace both ventricles.
D. This is inaccurate because a DDD pacemaker does not fire with every heartbeat; it only fires when the heart’s natural electrical activity is insufficient.

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Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient whose blood type is A-. The nurse knows that this patient can receive the following blood types:(SELECT ALL THAT APPLY)

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

Explanation

The nurse is providing discharge instructions to a client who has had a permanent pacemaker inserted. The information in the chart indicates that the device is a DDD. What will the nurse explain about this pacemaker?

Correct Answer is B

Explanation

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