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 B
Explanation
Rationale:
A. Auscultate bowel sounds: While assessing bowel sounds can be important, it is not the priority action in this situation. The client is experiencing nausea, and the priority is to ensure their airway and safety, not just bowel function.
B. Turn the client on their side: Turning the client on their side is the priority action. This position helps prevent aspiration in case the client vomits, ensuring the airway remains clear and reducing the risk of aspiration pneumonia, especially after sedation.
C. Administer ondansetron: While ondansetron is effective for treating nausea, it is not the priority action in this case. The nurse should first ensure the client's safety by positioning them appropriately to prevent aspiration before administering medication.
D. Ensure suction equipment is available: Having suction equipment available is important for safety, but the immediate priority is positioning the client to prevent aspiration. Once the client is positioned safely, suction can be used if necessary, or be obtained if unavailable.
Correct Answer is D
Explanation
Rationale:
A. Increase the oxygen flow rate by 1 L if the client experiences dyspnea: Oxygen therapy should be adjusted according to the prescribed rate by the healthcare provider. Dyspnea should be assessed, but changes in oxygen flow require professional supervision.
B. Replace cotton blankets with wool and synthetic blankets: Cotton is a safer material for individuals using oxygen therapy, as wool and synthetic fibers are more likely to generate static electricity, increasing the risk of fire. Cotton is less flammable and more appropriate.
C. Store oxygen tanks on their side when not in use: Oxygen tanks should be stored upright to ensure stability and prevent the valve from becoming damaged. Storing them on their side can lead to dangerous situations, such as the tank rolling or the valve being compromised.
D. Notify the fire department that oxygen is in use in the home: Notifying the fire department is an important safety measure when using oxygen therapy. Oxygen is highly flammable, and it is critical for the fire department to be aware of its presence in the home in case of an emergency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today