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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.

B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.

C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.

D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.

A. "Wear an underwire bra between feedings." B. "Cover your breasts immediately after feedings." C. "Apply cold compresses to your breasts before feedings." D. "Try to have your baby empty your breasts with each feeding."

Correct Answer is D

Explanation

A. Wearing an underwire bra between feedings can compress the breasts and potentially lead to mastitis. Nursing bras without underwire are recommended.

B. Covering the breasts immediately after feedings can trap moisture and promote bacterial growth, increasing the risk of mastitis.

C. Cold compresses can help relieve discomfort from engorgement, but applying them before feedings may hinder milk flow and emptying of the breasts, which could increase the risk of mastitis.

D. Ensuring the baby fully empties the breasts with each feeding helps prevent engorgement and decreases the risk of mastitis by promoting effective milk removal.

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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?

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