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 C

Explanation

A. Cryoprecipitate is indicated for low fibrinogen or clotting factor issues, but the client’s primary issue
here is anemia and thrombocytopenia.
B. FFP is used to replace clotting factors. While it could be considered in certain situations, in this case, the primary concern is the severe anemia and thrombocytopenia.
C. This is the most appropriate choice, as the patient has low hemoglobin (anemia) and a very low platelet count, both of which require packed red blood cells and platelets.
D. This combination is typically used for clotting factor issues, not anemia and thrombocytopenia.

A. fine crackles B. wheezes C. rhonchi D. vesicular sounds

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.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

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 C

Explanation

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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