The nurse is caring for a client immediately following the insertion of a permanent pacemaker. Which intervention should be included in the plan of care?

Teach the client how to change the pacemaker dressing

Immobilize the affected arm using a sling

Arrange for ancillary personnel to feed the client

Monitor urine output every two hours

Answer and Explanation

The Correct Answer is B

A. Teach the client how to change the pacemaker dressing: Client education is important but not a priority in the immediate post-procedure phase. Dressing changes should initially be performed using sterile technique by clinical staff to prevent infection at the insertion site.

B. Immobilize the affected arm using a sling: After pacemaker insertion, the affected arm (usually on the side of the implantation) should be immobilized or limited in movement to prevent lead dislodgment. Elevating the arm above the shoulder or excessive motion can compromise pacemaker lead placement during the early healing period.

C. Arrange for ancillary personnel to feed the client: Assistance with feeding is only necessary if the client has physical or cognitive limitations. This is not a routine or priority intervention following pacemaker insertion unless clinically indicated by other assessments.

D. Monitor urine output every two hours: Frequent monitoring of urine output is not directly related to pacemaker insertion unless there are other concerns such as fluid imbalance or renal dysfunction. It's not a standard intervention in the immediate care plan for this procedure.

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Correct Answer is A

Explanation

A. Narrowed pulse pressure: Aortic stenosis leads to obstruction of blood flow from the left ventricle to the aorta during systole, reducing systolic pressure while diastolic pressure remains unchanged or slightly elevated. This results in a narrowed pulse pressure, a classic finding in moderate to severe aortic stenosis.

B. Sinus tachycardia: While tachycardia can occur in response to decreased cardiac output or stress, it is not a defining feature of aortic stenosis. The hallmark findings relate more directly to fixed cardiac output and valve obstruction.

C. Apical diastolic murmur: Aortic stenosis produces a systolic ejection murmur, best heard at the right second intercostal space and radiating to the carotids. An apical diastolic murmur would suggest mitral stenosis or other diastolic valve pathology.

D. S3 heart sound: An S3 is more indicative of volume overload and heart failure rather than valvular stenosis. While advanced aortic stenosis can lead to heart failure, the S3 is not a primary or early manifestation of this condition.

A. calculate the number of small squares between one QRS complex and the next one and divide by 1500. B. use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10. C. count the number of large squares in the R-R interval and divide by 300. D. print a 1-minute ECG strip and count the number of QRS complexes.

Correct Answer is B

Explanation

A. calculate the number of small squares between one QRS complex and the next one and divide by 1500: This method provides an accurate heart rate calculation, but it is more time-consuming and typically used when precision is needed. It is not the quickest method for rapid bedside estimation of rate.

B. use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10: This is the fastest and most commonly used method for quickly estimating heart rate on an ECG strip. By counting the QRS complexes in a 6-second interval and multiplying by 10, the nurse gets an approximate beats-per-minute rate.

C. count the number of large squares in the R-R interval and divide by 300: This method also provides a quick estimate of heart rate but is best suited for regular rhythms. If the rhythm is irregular, this approach can yield inaccurate results.

D. print a 1-minute ECG strip and count the number of QRS complexes: While accurate, this method is inefficient for quick bedside estimation and is rarely used in practice for rapid assessment due to the time it takes to obtain and interpret a full-minute strip.

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The nurse is caring for a client immediately following the insertion of a permanent pacemaker. Which intervention should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that which of the following is a manifestation of aortic stenosis?

Correct Answer is A

Explanation

When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

Correct Answer is B

Explanation

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