A client who was discharged from the hospital 2 days ago after having a permanent pacemaker placed presents to the emergency department with sharp chest pain and difficulty breathing. Which assessment findings require the highest priority intervention?

BP 105/70 manually & flat neck veins

Equal breath sounds with a respiratory rate of 28

Distended neck veins & muffled heart sounds

Heart rate 105 & respiratory rate of 28

Answer and Explanation

The Correct Answer is C

A. BP 105/70 manually & flat neck veins: This blood pressure is within a low-normal range, and flat neck veins suggest no evidence of right-sided heart failure or cardiac tamponade. Though the patient needs evaluation, these findings are not emergent.

B. Equal breath sounds with a respiratory rate of 28: A mildly elevated respiratory rate can indicate distress, but equal breath sounds suggest the absence of pneumothorax or hemothorax. While the patient is symptomatic, this finding alone doesn't demand the most urgent intervention.

C. Distended neck veins & muffled heart sounds: These are classic signs of cardiac tamponade, a life-threatening emergency that can occur due to pacemaker lead perforation. This condition results in fluid accumulation in the pericardial sac, impairing cardiac output and requiring immediate intervention such as pericardiocentesis.

D. Heart rate 105 & respiratory rate of 28: These are signs of physiological compensation and indicate stress or early decompensation. However, without signs like neck vein distention or muffled heart sounds, they are less critical than the findings in option C.

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Correct Answer is A

Explanation

A. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and an unmeasurable PR interval. The ventricular rate can vary (in this case, 92/min), and QRS duration is usually normal. These findings match the classic ECG criteria for atrial fibrillation.

B. Sinus bradycardia: Sinus bradycardia features a regular rhythm, visible P waves before each QRS, and a rate below 60 bpm. The client's rate is 92 and the rhythm is irregular, ruling out this option.

C. Supraventricular tachycardia: SVT typically presents with a regular, rapid rhythm, often over 150 bpm, and P waves may be hidden in the preceding T wave. The client’s rate is 92 with an irregular rhythm, which does not fit SVT.

D. First-degree heart block: First-degree AV block is defined by a prolonged PR interval (>0.20 seconds) with otherwise normal sinus rhythm. In this case, the PR interval is unmeasurable and the rhythm is irregular, making this diagnosis unlikely.

A. Ensure all tubing connections are tightened B. Apply a pressure dressing to the insertion site C. Perform an Allen's test D. Obtain a portable x-ray to confirm placement

Correct Answer is A

Explanation

A. Ensure all tubing connections are tightened: Tight tubing connections are critical in preventing accidental disconnection, which can result in rapid blood loss and air embolism. Arterial lines are under high pressure, so securing all connections is a top priority to ensure patient safety and maintain line integrity.

B. Apply a pressure dressing to the insertion site: A transparent occlusive dressing not a pressure dressing is used for arterial lines to allow for site visualization and reduce the risk of infection. A pressure dressing could obscure signs of bleeding or compromise the catheter’s position.

C. Perform an Allen's test: Allen’s test is performed prior to radial arterial line insertion to assess collateral circulation via the ulnar artery for preventing ischemic complications if the radial artery is compromised. Performing the test afterward does not prevent complications and is no longer relevant once the catheter is placed.

D. Obtain a portable x-ray to confirm placement: X-rays are used to confirm the placement of central lines, not peripheral arterial lines like the radial line. Arterial line placement is confirmed by waveform analysis and blood return, not imaging.

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A client who was discharged from the hospital 2 days ago after having a permanent pacemaker placed presents to the emergency department with sharp chest pain and difficulty breathing. Which assessment findings require the highest priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nursing is caring for a patient who has had a left radial arterial line inserted 10 minutes ago. To reduce the risk of complications, what is the priority nursing intervention?

Correct Answer is A

Explanation

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