Difficulty: Medium
Average Score: 74%
Simulated
The nurse is caring for the client immediately following insertion of a permanent pacemaker via the right subclavian vein approach. Which intervention should the nurse include in the clientÔÇÖs plan of care to best prevent pacemaker lead dislodgement?
Correct answer
B
Rationale
Limiting arm and shoulder activity initially and up to 24 hours after the pacing leads are implanted helps prevent lead dislodgement. Often an arm sling is used as a reminder to the client to limit arm activity. Inspecting the incision, using a walker, and chest x-ray do not directly prevent lead dislodgement.