Symptomatic Bradycardia
A nurse is caring for a 60-year-old male client in the medical-surgical unit who was recently admitted with symptomatic bradycardia and has undergone permanent pacemaker insertion.
Complete the following sentence by using the list of options.
The nurse is caring for the client immediately following the insertion of the permanent pacemaker. The nurse should monitor the client for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The nurse is caring for the client immediately following the insertion of the permanent pacemaker. The nurse should monitor the client for hematoma at the insertion site and pacemaker failure to capture.
Rationale for correct answers:
Hematoma at the insertion site is a common complication following pacemaker placement due to vascular injury during lead insertion or anticoagulation therapy. It may present as swelling, bruising, or firmness near the generator pocket and can lead to discomfort or device displacement if not addressed promptly.
Pacemaker failure to capture occurs when the pacemaker delivers an electrical impulse but fails to stimulate myocardial contraction. It can result in persistent bradycardia or asystole. Monitoring for pacing spikes on telemetry without corresponding QRS complexes is critical. This is particularly important given the client's low apical pulse of 42/min, which suggests potential malfunction despite recent device placement.
Rationale for incorrect answers:
Increased respiratory rate is already documented in the client’s baseline assessment. While notable, it is not a pacemaker-specific complication and may reflect pre-existing symptoms rather than an acute issue needing focused post-pacemaker monitoring.
Elevated potassium levels (normal: 3.5–5.0 mEq/L) are borderline in this client (5.1 mEq/L), but mild elevation is not an immediate concern in the context of pacemaker insertion unless rapidly rising, which isn’t evident.
Decreased oxygen saturation (normal: >94%) is currently 94% and improving. This level does not require urgent intervention unless it continues to decline or respiratory distress worsens.
Peripheral edema is not present and usually develops gradually. It is more indicative of chronic heart failure rather than an acute post-pacemaker concern.
Elevated temperature (normal: 36.5–37.5°C) is not present; the client's temperature is normal. Fever would suggest infection, which is unlikely this soon after insertion.
Decreased blood pressure (normal: >90/60 mm Hg) is not present. BP is stable at 104/68 mm Hg, not warranting concern for hypotension.
Take-home points:
- Monitor for hematoma and lead displacement as common immediate complications of pacemaker insertion.
- Pacemaker malfunction may present as bradycardia with absent capture on ECG despite pacing spikes.
- Differentiate symptoms of pacemaker issues from preexisting cardiac conditions like sick sinus syndrome or AV block.
- Evaluate post-procedure symptoms in the context of baseline vital signs and device-specific risks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
1 cup of canned black beans is an excellent source of non-heme iron. Iron is a crucial component of hemoglobin synthesis, which is essential for oxygen transport in red blood cells. Increasing dietary iron intake helps to replenish iron stores and alleviate fatigue associated with iron deficiency anemia.
Choice B rationale
8 oz whole milk provides calcium and vitamin D but is a poor source of iron. In fact, calcium can sometimes interfere with iron absorption, making it an unsuitable choice for a client specifically aiming to increase iron intake to combat iron deficiency anemia.
Choice C rationale
1.5 oz raisins provide some iron, but the quantity is relatively small compared to other iron-rich foods. While a healthy snack, it would not be the primary recommendation for a client requiring significant iron replenishment due to fatigue from anemia.
Choice D rationale
8 oz black tea contains tannins, which are compounds known to inhibit the absorption of non-heme iron from plant-based foods. Therefore, consuming black tea with meals would counteract efforts to increase iron levels and is not recommended for iron deficiency anemia.
Correct Answer is C
Explanation
Choice A rationale
Elevated WBC is not a primary manifestation of idiopathic thrombocytopenic purpura (ITP). ITP is an autoimmune disorder characterized by platelet destruction, leading to thrombocytopenia. While some immune disorders might show WBC abnormalities, the hallmark of ITP is low platelet count, not an elevated white blood cell count, which would suggest infection or another inflammatory process.
Choice B rationale
Fatigue is a common non-specific symptom that can be present in many conditions, including anemia, which may result from significant bleeding associated with severe thrombocytopenia in ITP. However, it is not the most direct or specific manifestation that a nurse would primarily monitor for in ITP, as other more objective signs of bleeding are more indicative of the disease's active state.
Choice C rationale
Ecchymosis, which refers to subcutaneous extravasation of blood resulting in bruising, is a direct manifestation of low platelet counts in idiopathic thrombocytopenic purpura (ITP). Reduced platelet aggregation and adhesion impair the body's ability to form clots, leading to spontaneous bleeding into the skin and other tissues, making ecchymosis a key indicator of the disease's activity.
Choice D rationale
Fever is not a typical manifestation of idiopathic thrombocytopenic purpura (ITP) itself. While a patient with ITP might develop a fever if they have an underlying infection or another co-occurring illness, fever is not directly caused by the autoimmune destruction of platelets characteristic of ITP. Monitoring for fever would be more relevant in the context of infection or other systemic inflammatory processes.
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