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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vancomycin is not typically associated with hepatotoxicity.
B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.
C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.
D. Hypertension is not a common adverse reaction associated with vancomycin therapy.
Correct Answer is A
Explanation
A.
A. Justice refers to fairness and equity in the distribution of resources and the treatment of
individuals. By spending an equal amount of time with each client regardless of their background or actions, the nurse is demonstrating the principle of justice.
B. Autonomy refers to respecting the right of individuals to make their own decisions about their healthcare. While important, it does not directly relate to the nurse's equal allocation of time.
C. Nonmaleficence refers to the duty to do no harm. While relevant to nursing care, it does not directly apply to the equal distribution of time among clients.
D. Veracity refers to truthfulness and honesty in communication. While important, it does not directly relate to the allocation of time among clients.
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