A client has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines the P-R interval is 0.20 seconds. The most appropriate intervention by the nurse would be to

Notify the health care provider immediately.

Document the finding and continue to monitor the patient.

Prepare the patient for temporary pacemaker insertion.

Give atropine per agency dysrhythmia protocol.

Answer and Explanation

The Correct Answer is B

A. Notifying the health care provider immediately is not necessary, as the PR interval is at the upper limit of normal (0.20 seconds) and the client is stable.
B. Document the finding and continue to monitor the patient – A PR interval of 0.20 seconds with a normal heart rate and rhythm does not require intervention; just ongoing observation.
C. Prepare the patient for temporary pacemaker insertion – This is used for serious conduction blocks or symptomatic bradycardia, which are not present here.
D. Give atropine per agency dysrhythmia protocol – Atropine is used for symptomatic bradycardia, which this client does not exhibit.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse should monitor the client for pneumothorax and lead dislodgement following permanent pacemaker placement.

Rationale

Pneumothorax: The procedure involves central venous access, often via the subclavian vein, which increases the risk of puncturing the pleura and causing a pneumothorax. Signs include:

Lead dislodgement: Movement or tension on the pacing lead can result in loss of pacemaker capture or failure to pace effectively. This is a priority during the first 24 hours. Indicators include:

A. Increased blood pressure B. Increase hematocrit C. Increased respiratory rate D. Increased heart rate E. Increased temperature

Correct Answer is ["A","C","D"]

Explanation

A. Increased blood pressure occurs due to excess fluid volume increasing vascular pressure.
B. Hematocrit typically decreases in fluid overload due to dilution, not increases.
C. Increased respiratory rate is common due to pulmonary congestion or edema.
D. Increased heart rate occurs as the heart works harder to manage the excess fluid volume.
E. Increased temperature is not a typical finding in fluid overload.

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A client has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines the P-R interval is 0.20 seconds. The most appropriate intervention by the nurse would be to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

After receiving report on the following clients, which client should the nurse assess first?

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