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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B. This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C. When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D. While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.
Correct Answer is D
Explanation
A. Diltiazem is a calcium channel blocker that can be used to manage conditions like atrial fibrillation or hypertension by slowing the heart rate and reducing blood pressure. However, it may not be the most appropriate drug in the acute setting for heart failure with dyspnea.
B. Nitroglycerine is a vasodilator that helps reduce preload and afterload, which can be beneficial in heart failure. However, it primarily works by reducing the workload on the heart and may help with fluid overload but may not directly address anxiety.
C. Verapamil is another calcium channel blocker that slows the heart rate and reduces the heart's workload. While it may be useful for controlling tachyarrhythmias, it is not the best option for managing acute heart failure with severe dyspnea and anxiety.
D. Morphine is an opioid that can be used in acute heart failure to reduce both anxiety and respiratory distress. It works by reducing the sympathetic nervous system response, decreasing heart rate and blood pressure, and providing a sense of calm, which reduces anxiety. It also reduces preload by venodilation and helps manage severe dyspnea.
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