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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Breast cancer treated with chemotherapy and radiation: While cancer and its treatments can suppress the immune system, they are not direct causes of infectious endocarditis. The condition is more closely related to bacteremia and structural heart damage.

B. Periodontal disease and gum surgery three months ago: Periodontal disease involves chronic bacterial infection of the gums and supporting structures of the teeth, this transient bacteremia can lead to infectious endocarditis. Oral infections and invasive dental procedures can introduce bacteria into the bloodstream, particularly streptococci, which can colonize damaged heart valves and cause infectious endocarditis.

C. Type II diabetic for ten years: Diabetes increases the risk of infection generally, but it is not a specific cause of endocarditis. Without a portal of entry or bacteremia, the condition alone is not strongly associated with endocarditis.

D. Myocardial infarction one year ago: A prior MI may result in reduced cardiac function but does not directly lead to infectious endocarditis unless it has resulted in damaged valves or introduced infection, which is not indicated here.

A. Diaphoresis, hypertension B. Palpitations, shortness of breath C. Systolic murmur, severe anxiety D. Visual changes, anorexia

Correct Answer is B

Explanation

A. Diaphoresis, hypertension: While diaphoresis may occur in response to the discomfort or anxiety caused by a rapid heart rate, hypertension is not a typical feature of atrial flutter. The rapid ventricular response can more often lead to hypotension if cardiac output is compromised.

B. Palpitations, shortness of breath: These are hallmark symptoms of rapid atrial flutter. Palpitations result from the fast, irregular atrial contractions, while shortness of breath may occur due to decreased cardiac output and poor ventricular filling during rapid rates.

C. Systolic murmur, severe anxiety: Atrial flutter is not typically associated with a systolic murmur unless there is a pre-existing valvular condition. Anxiety may be present but is a nonspecific response and not as directly linked to atrial flutter as palpitations and dyspnea.

D. Visual changes, anorexia: These symptoms are not characteristic of atrial flutter. Visual changes may occur with severe hypotension or embolic events, and anorexia may be seen in chronic illness, but neither is directly tied to the acute presentation of atrial flutter.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is caring for a client with suspected infectious endocarditis. Which information obtained in the health history could contribute to the development of this problem?

Correct Answer is B

Explanation

Which physical assessment findings would the nurse anticipate for a client with rapid atrial flutter?

Correct Answer is B

Explanation

The client hospitalized with infective endocarditis develops sharp flank pain and hematuria. The nurse notifies the physician, recognizing that these clinical manifestations may indicate:

A client with paroxysmal supraventricular tachycardia asks the nurse why the health care provider (HCP) is going to perform carotid sinus massage. The nurse educates the client about the treatment. Which statement by the client indicates that the teaching has been effective?

A client has a triple lumen subclavian central venous catheter (CVC) with D51/2NS infusing through one lumen (port) at 75 mL per hour. The nurse has an order to transfuse one unit of packed red blood cells (PRBCs). The nurse's safest action is to:

The nurse understands that which of the following medications is a potassium channel blocker?

The nurse identifies the following rhythm on the cardiac monitor. Which treatment modality will the nurse anticipate for this client?

The nurse administers atropine 0.5 mg IV to a client. Which action should be performed after the client has received this medication?

The nurse is caring for a client in the coronary care unit and the monitor depicts the rhythm shown below. What is the nurse's interpretation of this rhythm?

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?