The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

Document that the client is experiencing a paced rhythm.

Reposition the ECG leads and obtain another recording.

Assess the client for symptoms of decreased cardiac output.

Notify the healthcare provider (HCP) of the telemetry recording.

Answer and Explanation

The Correct Answer is A

A. Document that the client is experiencing a paced rhythm. A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
B. Reposition the ECG leads and obtain another recording. If the ECG showed artifact, lead displacement, or interference, repositioning the leads might be appropriate. However, the presence of consistent pacemaker spikes before each QRS complex suggests proper pacemaker function rather than a lead issue.
C. Assess the client for symptoms of decreased cardiac output. A paced rhythm is expected after pacemaker insertion and does not necessarily indicate hemodynamic instability. While assessment is always important, there is no indication that the client is experiencing decreased cardiac output symptoms such as hypotension, dizziness, or altered mental status.
D. Notify the healthcare provider (HCP) of the telemetry recording. Routine paced rhythms do not require immediate provider notification unless there are malfunctions such as failure to capture, failure to sense, or failure to pace. Since the pacemaker is functioning appropriately, notifying the HCP is unnecessary.

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Correct Answer is B

Explanation

A. Administer famotidine 20 mg IV. Famotidine is a histamine-2 receptor antagonist used for stress ulcer prophylaxis in critically ill patients. While this medication may be beneficial, it is not the priority intervention based on the insulin protocol and the client's blood glucose level.
B. Titrate insulin infusion by 1 unit/hour. The client’s blood glucose is 160 mg/dL, which falls within the 150–199 mg/dL range according to the insulin protocol. The protocol directs the nurse to increase the insulin drip rate by 1 unit/hour to maintain blood glucose levels below 150 mg/dL. This is the most immediate and appropriate action.
C. Increase dopamine 2 mcg/kg. The client’s MAP is 66 mmHg, which meets the protocol goal of keeping MAP >65 mmHg. There is no indication for increasing dopamine at this time, as the blood pressure is already within the target range.
D. Raise oxygen by 10 percent. The client is on 50% FiO₂ via a face mask with an oxygen saturation of 92%, which is adequate oxygenation for a critically ill patient. Increasing FiO₂ unnecessarily may contribute to oxygen toxicity and is not required based on current oxygenation status.

A. Measure the client's abdominal girth. B. Monitor the client's recent hemoglobin levels. C. Prepare for nasogastric tube (NGT) insertion. D. Notify the healthcare provider (HCP) of the client's status.

Correct Answer is D

Explanation

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

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The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

Correct Answer is D

Explanation

Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the ABG values, the nurse knows that the client has dropdownrelated todropdown

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