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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Burning sensation is a potential adverse effect of permethrin 5% cream application. It may cause transient discomfort or irritation at the site of application.
B. Discoloration is not a common adverse effect associated with permethrin cream application.
C. Photosensitivity is not typically associated with the use of permethrin cream.
D. Alopecia (hair loss) is not a common adverse effect of permethrin cream application.
Correct Answer is D
Explanation
A. Allowing the infant to suck on a pacifier during tube feedings can lead to aspiration or choking and is not recommended.
B. Placing enough formula for 12 hours in the feeding container may lead to formula spoilage and contamination, as formula should be prepared fresh for each feeding.
C. Changing the tube feeding setup every 36 hours is not typically necessary unless there are signs of contamination or malfunction. The frequency of changing the setup should be based on institutional policies and manufacturer recommendations.
D. Flushing the tube with water before and after feedings helps ensure proper hydration and prevents tube blockage. A volume of 30 mL is commonly recommended for infants.
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