The nurse is caring for a client with a permanent pacemaker. The client's monitor shows a pacemaker spike prior to the p wave. What would be the nurse's best action?

Increase the pacemaker sensitivity

Document that the pacemaker is regular

Set the pacemaker to the asynchronous mode

Document that the atria are being paced

Answer and Explanation

The Correct Answer is D

A. Increase the pacemaker sensitivity: Adjusting pacemaker sensitivity is a technical function typically managed by a cardiologist or device technician. There is no indication from the information provided that the pacemaker is under- or over-sensing, so no adjustment is warranted.

B. Document that the pacemaker is regular: While the pacemaker may be functioning regularly, this statement is vague and does not accurately describe the observed pacing activity. The key observation is the spike occurring before the P wave, which requires more specific documentation.

C. Set the pacemaker to the asynchronous mode: Asynchronous pacing means the pacemaker fires at a set rate regardless of the patient's intrinsic rhythm and is generally reserved for specific situations such as during surgery or when interference with sensing is suspected. There is no evidence of pacemaker malfunction or need to override sensing in this scenario.

D. Document that the atria are being paced: A pacemaker spike immediately before the P wave indicates atrial pacing. This means the pacemaker is stimulating the atria, leading to atrial depolarization. This is the appropriate interpretation and should be documented clearly.

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Correct Answer is ["200"]

Explanation

Volume ordered is 1 L.

Convert the total volume to milliliters (mL)

1 L = 1000 mL.

Total volume in mL = 1 L × 1000 mL/L = 1000 mL

Total infusion time = 5 hours

Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Total volume (mL) / Total infusion time (hours)

= 1000 mL / 5 hours

= 200

The appropriate setting is 200 mL/hr.

A. the P-P and R-R distances are equal and regular B. the rhythm rate using a 3-second strip C. the duration of the U waves D. there is a QRS complex after each P wave E. P waves are present, upright and rounded

Correct Answer is ["A","B","D","E"]

Explanation

A. The P-P and R-R distances are equal and regular: Equal and regular spacing between P-P and R-R intervals indicates that both atrial and ventricular rhythms are regular. This is a fundamental aspect of rhythm interpretation, helping to distinguish between regular and irregular rhythms such as atrial fibrillation or sinus arrhythmia.

B. The rhythm rate using a 3-second strip: Assessing the heart rate using a 3-second or 6-second ECG strip helps determine whether the rhythm is bradycardic, tachycardic, or within normal limits, which is crucial for accurate rhythm classification.

C. The duration of the U waves: U waves are typically small and follow the T wave. Although their presence can suggest conditions like hypokalemia, they are not routinely assessed in basic rhythm identification. Evaluating U wave duration is more relevant in electrolyte imbalance analysis than in identifying rhythm type.

D. There is a QRS complex after each P wave: A consistent QRS following every P wave indicates effective conduction from the atria to the ventricles. Each atrial depolarization (P wave) should be followed by a ventricular depolarization (QRS complex) if the signal is being conducted properly through the AV node. This finding supports a diagnosis of sinus rhythm and helps rule out AV blocks, where conduction may be delayed or blocked entirely.

E. P waves are present, upright and rounded: P waves that are upright and rounded in lead II suggest the electrical impulse is originating from the SA node. Their presence and morphology are essential criteria for identifying sinus rhythm and differentiating it from atrial arrhythmias like flutter or fibrillation.

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The nurse is caring for a client with a permanent pacemaker. The client's monitor shows a pacemaker spike prior to the p wave. What would be the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A post-op client is to receive the following: D5%W/0.45% NS 1 L to infuse over 5 hours. What is the appropriate setting on an infusion pump in milliliters per hour? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["200"]

Explanation

To properly identify a cardiac rhythm, the nurse will determine if the client's rhythm contains the following factors: (Select All that Apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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