A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?

Heart rate greater than 60/min

Pedal pulses 2+

Pacer spikes after the QRS complex

Distended jugular veins

Answer and Explanation

The Correct Answer is A

- A: A heart rate greater than 60/min indicates that the transcutaneous pacing is effectively maintaining a heart rate within a normal range, which is crucial for adequate cardiac output and systemic perfusion.
- B: While 2+ pedal pulses indicate good peripheral perfusion, they do not directly reflect the effectiveness of transcutaneous pacing in treating complete heart block.
- C: Pacer spikes should appear before the QRS complex to show that the pacing stimulus is being delivered appropriately. Spikes after the QRS complex suggest that the pacing is not capturing the heart effectively.
- D: Distended jugular veins would be more indicative of heart failure or fluid overload and do not directly relate to the effectiveness of pacing therapy.

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Correct Answer is A

Explanation

A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.

B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.

C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.

D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.

A. Blood glucose level of 120 mg/dL B. Serum sodium 138 mEq/L C. Oral temperature of 37.6°C (99.7°F) D. Weight increase of 2 kg (4.4 lb) in the past 24 hr

Correct Answer is D

Explanation

A. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.

B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.

C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.

D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.

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A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture?

Correct Answer is A

Explanation

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Correct Answer is D

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