The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Instruct the client to remain quiet and refrain from activity

Continue to monitor as this may occur with a transvenous pacemaker

Assess the client's blood pressure and take an apical pulse

Notify the healthcare provider because the pacemaker is not sensing properly

Answer and Explanation

The Correct Answer is D

A.   Instructing the client to remain quiet may reduce stress or activity but does not address the issue of the pacemaker not sensing properly.
B.   Continuing to monitor without addressing the malfunction is inappropriate because this could lead to complications or inappropriate pacing.
C.   Assessing blood pressure and pulse is important for patient safety but the priority is addressing the pacemaker's malfunction by notifying the healthcare provider.
D.   The pacemaker should sense the client's intrinsic beats to avoid inappropriate pacing. If it is firing on the T wave or at inappropriate times, it indicates a sensing issue that needs to be addressed by the healthcare provider.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Ventricular fibrillation (VF) is characterized by a chaotic, rapid, and irregular electrical activity on the ECG, with no identifiable QRS complexes, P waves, or T waves. The heart quivers ineffectively, leading to no blood flow or cardiac output, which results in rapid loss of consciousness and is life-threatening.

Immediate defibrillation is required to restore a normal rhythm. A high-energy shock is delivered to the heart to reset the electrical activity, potentially allowing the heart's natural pacemaker to regain control and resume normal function.

A. Heart rate 100 beats per minute B. + 3 peripheral edema C. Respiratory rate of 24 at rest D. Alert and oriented X 3

Correct Answer is D

Explanation

A. A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B. Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C. A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D. Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Correct Answer is D

Explanation

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The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Complete the following sentences with the list of drop down The nurse assesses the client's rhythm on the monitor. The patient is unresponsive with no pulse. The nurse identifies the rhythm asdropdown. The nurse's priority action isdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

Correct Answer is D

Explanation

The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV. Which parameter would the nurse use to best evaluate if the client is responding to this medication?

A patient is prescribed 250 mL of packed red blood cells to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

The nurse administers atropine 0.5 mg IV to a client. Which action should be performed after the client has received this medication?

The nurse is reviewing the laboratory values for the client diagnosed with heart failure and notes the sodium level is 128 mEq/L (normal 135-145mEq/L). How should the nurse interpret this finding?

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