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 B

Explanation

A. A low hemoglobin level indicates anemia, not heart failure. While anemia can exacerbate heart failure, it is not the primary indicator.
B. BNP is a biomarker that is elevated in response to heart failure. A level above 100 pg/mL is suggestive of heart failure, and 410 pg/mL indicates significant heart stress and likely acute heart failure.
C. A low sodium level (hyponatremia) can occur in heart failure, but it is not specific enough to confirm the diagnosis. BNP is a more direct indicator of heart failure.
D. This is a normal fibrinogen level and does not indicate heart failure. Fibrinogen is more associated with clotting disorders.

A. Perform a 12 lead EKG and request an order for bumetanide 0.5 mg IV B. Administer pantoprazole sodium 40 mg by mouth to decrease GI distress C. Administer carvedilol 10 mg by mouth and reassess in 30 minutes D. Complete the remainder of the assessment and continue to monitor

Correct Answer is D

Explanation

A. The 12-lead EKG might be unnecessary right now, especially since the client has no other alarming symptoms. Bumetanide is also not indicated for nausea or tachycardia in this scenario.
B. There is no clear indication that the nausea is related to acid reflux or GI distress that would justify pantoprazole.
C. The tachycardia could be physiological, and treating it with a beta-blocker is unnecessary unless there is a more concerning underlying cause (like heart failure or ischemia). The priority here is not pharmacological intervention but monitoring the client's overall condition.
D. This action allows for appropriate monitoring of the client's condition. Sinus tachycardia may resolve on its own without intervention, and the client doesn't exhibit severe symptoms requiring immediate pharmacologic treatment.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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