The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

The pacemaker is pacing abnormally

Biventricular, pacing in both ventricles

Atrial paced rhythm

Atrial and ventricular pacing

Answer and Explanation

The Correct Answer is D

A.   This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B.   This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C.   This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D.   This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.

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Correct Answer is B

Explanation

A. Fine crackles - Fine crackles are short, popping sounds usually heard during inspiration, indicative of fluid in the lungs.
B. Wheezes - Wheezes are continuous, high-pitched musical sounds caused by narrowed airways, often seen in asthma, bronchitis, or other respiratory conditions.
C. Rhonchi - Rhonchi are low-pitched, rattling sounds that occur when air flows through thick mucus or secretions in the larger airways.
D. Vesicular sounds - Vesicular breath sounds are normal lung sounds heard over most lung fields during inspiration. They are not continuous and high-pitched.

A. “I will be ready to resume participation in the football league in two weeks.! B. 'It is safe to use the microwave oven to heat up food." C. “I can use my cellphone as long as I keep it 6 inches away from the device." D. "The defibrillator will feel like a kick or blow to the chest if it fires."

Correct Answer is A

Explanation

A. This statement indicates a need for further education. After receiving an ICD, clients must refrain from engaging in vigorous physical activities such as contact sports (e.g., football) for a longer period of time to avoid injury or triggering the defibrillator. A longer recovery period is typically recommended.
B. This is correct. Microwaves do not affect the function of an ICD, so it is safe to use one.
C. This is correct. The client should keep their cellphone at least 6 inches away from the ICD to avoid interference with the device.
D. This is correct. Clients may experience a sudden, forceful sensation similar to a kick or blow when the ICD delivers a shock to correct an arrhythmia.

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The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Upon assessment of the client's lungs, the nurse hears continuous, high-pitched, musical sounds. This should be documented as:

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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