A nurse is monitoring a client's heart rhythm following insertion of a permanent pacemaker. Which of the following images should the nurse expect?
A
B
C
D
The Correct Answer is C
Rationale:
A. Ventricular Tachycardia (VTach): Regular, very fast rhythm (150–250 bpm), Wide QRS complexes, No visible P waves. Interpretation: Life-threatening rhythm, not expected after pacemaker. Immediate intervention is needed.
B. Atrial Fibrillation (AFib): Irregularly irregular rhythm, No distinct P waves, Narrow QRS complexes. AFib can exist with or without a pacemaker, but not expected immediately post-insertion unless patient has pre-existing AFib.
C. Rhythm: Ventricular paced rhythm (normal post-pacemaker). Regular rhythm -60 bpm, Narrow QRS complexes following sharp pacing spikes, Pacing spikes appear just before QRS complexes. Expected ECG after permanent pacemaker insertion — it shows effective ventricular capture.
D. Irregular rhythm, Alternating normal and wide QRS complexes, Wide QRS possibly not preceded by pacing spike, not expected right after pacemaker insertion. Suggests poor pacer function or ventricular ectopy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Provide the client with high-protein meals: High-protein meals are important for tissue repair and healing, especially in clients at risk for pressure ulcers. Adequate nutrition, including protein, is essential to promote skin integrity and prevent further skin breakdown.
B. Gently massage the reddened areas: Massaging reddened areas can increase tissue damage and worsen skin breakdown. Instead of massaging, the nurse should relieve pressure on those areas to prevent further injury.
C. Place the client in a supine position: The supine position might increase pressure on the client's scapulae. It is better to reposition the client to relieve pressure from affected areas, ideally by turning them to their side or using pillows to offload pressure.
D. Use hot water when cleaning the client's skin: Hot water can dry and irritate the skin, worsening the condition. The nurse should use lukewarm water and gentle, non-irritating products to clean the skin and prevent further damage.
Correct Answer is B
Explanation
Rationale:
A. Keep the casted leg flat for the first 24 hr: The casted leg should not be kept flat for the first 24 hours. Elevating the leg above the heart is important to reduce swelling and promote circulation. Keeping it flat could increase swelling and discomfort.
B. Report any drainage from the casted leg: It is important to report any drainage from the cast, as it could indicate infection or complications, such as a wound underneath the cast. Drainage, especially if it is blood-tinged or excessive, requires prompt evaluation.
C. Apply a heating pad to the casted leg: Applying a heating pad is not recommended as it could increase swelling or cause burns. It is important to keep the cast cool and dry and avoid applying heat, which could affect the skin or underlying tissue.
D. Use a cotton-tip applicator to relieve itching inside the cast: Using a cotton-tip applicator can be harmful because it might push debris deeper into the cast, increasing the risk of infection or injury.
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