A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?
Heart rate greater than 60/min
Pedal pulses 2+
Pacer spikes after the QRS complex
Distended jugular veins
The Correct Answer is A
- A: A heart rate greater than 60/min indicates that the transcutaneous pacing is effectively maintaining a heart rate within a normal range, which is crucial for adequate cardiac output and systemic perfusion.
- B: While 2+ pedal pulses indicate good peripheral perfusion, they do not directly reflect the effectiveness of transcutaneous pacing in treating complete heart block.
- C: Pacer spikes should appear before the QRS complex to show that the pacing stimulus is being delivered appropriately. Spikes after the QRS complex suggest that the pacing is not capturing the heart effectively.
- D: Distended jugular veins would be more indicative of heart failure or fluid overload and do not directly relate to the effectiveness of pacing therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Speaking directly into one of the client's ears may be ineffective if the client has bilateral hearing impairment or if the hearing impairment is not related to the ear anatomy.
B. Rephrasing sentences the client does not understand can help clarify communication and ensure the client receives necessary information.
C. Dropping voice volume at the end of sentences can make it difficult for the client to hear the entire message, especially if the client relies on lip-reading or amplification devices.
D. Exaggerating lip movements may not be helpful for all clients with hearing impairment and may not accurately convey the intended message. Instead, clear and natural lip movements should be used along with other communication strategies such as rephrasing sentences and facing the client directly.
Correct Answer is B
Explanation
- A: Diabetes mellitus is not listed as a contraindication for methylergonovine.
- B: Hypertension is a contraindication for methylergonovine because it can cause severe hypertension and other cardiovascular effects.
- C: Migraine headaches are not listed as a contraindication for methylergonovine.
- D: Hepatitis B is not listed as a contraindication for methylergonovine.
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