The nurse is caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply
Pacer spikes are adequate in number.
Pacer spikes occur directly before the P waves.
Pacer spikes occur directly before the QRS waves.
Pacer spikes occur on the T waves.
The heart rate is within programmed parameters.
Correct Answer : D,E
The traces that should require immediate follow-up by the nurse are:
● Pacer spikes occur directly before the T waves.
Pacer spikes occurring on the T waves indicate an issue with the pacemaker's timing or sensing. This could lead to inappropriate pacing or pacing during the refractory period, which can be detrimental to the client's heart function.
● The heart rate is outside of programmed parameters.
If the heart rate is outside of the programmed parameters set for the client's pacemaker, it may indicate a malfunction or failure of the device or a change in the client's cardiac status. It is important for the nurse to assess the client's condition and notify the healthcare provider for further evaluation and intervention.
Let's review the other options and explain why they do not require immediate follow-up:
Pacer spikes are adequate in number: This indicates that the pacemaker is delivering the appropriate number of electrical impulses as programmed. As long as the other parameters are normal, this finding does not require immediate follow-up.
Pacer spikes occur directly before the P waves: This is the desired and expected pattern for a pacemaker in normal sinus rhythm. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.
Pacer spikes occur directly before the QRS waves: This is also the desired and expected pattern for a pacemaker in clients with ventricular pacing. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.
The heart rate is within programmed parameters: If the heart rate falls within the programmed parameters set for the client's pacemaker, it indicates that the device is functioning appropriately in maintaining the desired heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The importance of ensuring the stockings are applied evenly with no pressure points: Compression stockings are designed to provide graduated pressure to the legs, helping improve blood flow and reduce swelling in individuals with venous insufficiency. It is crucial for the client to understand how to properly apply the stockings to maximize their effectiveness and prevent any complications. The nurse should emphasize the following points:
● Ensure the stockings are applied evenly: The stockings should be applied smoothly and evenly without any folds or wrinkles. This helps ensure that the pressure is distributed uniformly, enhancing their therapeutic effect.
● Check for pressure points: The client should be instructed to pay attention to any areas where the stockings may be causing excessive pressure or discomfort. Pressure points can impair circulation or cause skin damage. If pressure points are noticed, adjustments should be made to ensure proper fit and comfort.
● Follow manufacturer's instructions: The nurse should provide specific instructions regarding how to correctly don the compression stockings, including any specific guidelines provided by the manufacturer. This may include recommendations for the time of day to apply the stockings or any specific donning techniques.
The other options mentioned in the question are not essential information for the teaching plan:
The need to take anticoagulants concurrent with using compression stockings: While some individuals with venous insufficiency may require anticoagulant therapy, it is not directly related to the use of compression stockings. Anticoagulant therapy is typically prescribed for other reasons, such as prevention or treatment of blood clots.
The need to wear the stockings on a one day on, one day off schedule: Wearing compression stockings on a specific schedule of one day on, one day off is not a standard recommendation. The frequency and duration of wearing compression stockings may vary based on individual needs and healthcare provider's recommendations.
The importance of wearing the stockings around the clock to ensure maximum benefit: While consistent and regular use of compression stockings is important, it is not necessary to wear them around the clock. Healthcare providers typically provide specific guidelines on how long the stockings should be worn each day, which may vary based on the severity of venous insufficiency and individual factors.
Correct Answer is D
Explanation
Hypertension, or high blood pressure, is often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it has already caused damage to target organs such as the heart, blood vessels, kidneys, or brain. It is crucial for the client to understand that even if they do not experience symptoms, untreated or poorly controlled hypertension can lead to serious complications, including heart disease, stroke, kidney problems, and more.
While dietary changes and increasing physical activity are important lifestyle modifications for managing hypertension, it is not accurate to state that most people can control their blood pressure through these measures alone. Hypertension is a complex condition influenced by multiple factors, and many individuals require additional interventions, such as medication, to effectively manage their blood pressure.
Annual blood pressure checks are indeed important to monitor the effectiveness of treatment and ensure that blood pressure remains within the target range. However, this information is secondary to the understanding that hypertension is typically asymptomatic until target organ damage occurs.
Recognizing the potential risks associated with untreated or uncontrolled hypertension can motivate the client to adhere to their treatment plan and make necessary lifestyle changes.
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