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. Ventrogluteal - The ventrogluteal site is preferred for intramuscular injections in adults due to its proximity to large, deep muscles and minimal risk of injury to major nerves and blood vessels.

B. Dorsogluteal - The dorsogluteal site is not recommended for intramuscular injections due to the risk of injury to the sciatic nerve and superior gluteal artery.

C. Vastus lateralis - The vastus lateralis is a safe site for intramuscular injections, particularly in infants and young children.

D. Rectus femoris - The rectus femoris muscle is not typically used for intramuscular injections due to its superficial location and proximity to major blood vessels.

A. Healthy weight B. Malnutrition C. Overweight D. Obesity

Correct Answer is A

Explanation

A. A BMI of 20 falls within the healthy weight range for adults, indicating that the client's weight is appropriate for his height.

B. A BMI of 20 is not indicative of malnutrition. Malnutrition is typically associated with lower BMIs.

C. A BMI of 20 is not within the overweight range, as overweight is typically defined as a BMI between 25 and 29.9.

D. A BMI of 20 is not within the obesity range, as obesity is typically defined as a BMI of 30 or higher.

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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

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