A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Pacemaker spikes before each QRS complex

Pacemaker spikes after each QRS complex

Pacemaker spikes before each P wave

Pacemaker spikes with each T wave

Answer and Explanation

The Correct Answer is A

A. Pacemaker spikes before each QRS complex: This is the correct answer. In a client with a ventricular pacemaker, the pacemaker spikes should precede each QRS complex on the ECG strip. This indicates that the pacemaker is appropriately stimulating the ventricles to depolarize and initiate a heartbeat. The

presence of pacemaker spikes before each QRS complex signifies that the pacemaker is functioning properly and effectively pacing the ventricles.

B. Pacemaker spikes occurring after each QRS complex would suggest a malfunction or inappropriate timing of the pacemaker. In this scenario, the pacemaker would not be pacing the ventricles as intended. This would be an abnormal finding and would require further assessment and intervention.

C. Pacemaker spikes preceding each P wave would suggest pacing of the atria rather than the ventricles. This would indicate a different type of pacemaker (atrial pacemaker) or inappropriate pacing settings for a ventricular pacemaker. In either case, it would be considered abnormal for a ventricular pacemaker and would require evaluation and possibly reprogramming of the pacemaker.

D. Pacemaker spikes occurring with each T wave would be an abnormal finding and would suggest interference or oversensing by the pacemaker. This could lead to inappropriate pacing or dysrhythmias. It would require further investigation and correction to ensure proper pacemaker function.

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Correct Answer is D

Explanation

D. A drop in oxygen saturation may indicate inadequate oxygenation, which could be due to airway obstruction or retained secretions.

A. While audible expiratory wheezes may indicate airway obstruction or secretions, they do not necessarily indicate the need for suctioning in a patient receiving mechanical ventilation.

B. An elevated respiratory rate may suggest increased work of breathing, which could be due to retained secretions or airway obstruction. However, an elevated respiratory rate alone may not always indicate the need for suctioning.

C. The timing of the last suctioning episode is an important consideration when determining the need for suctioning. However, it should not be the sole indicator for when to suction.

A. Prepare to insert a central line. B. Administer oxygen via nasal cannula. C. Raise the foot of the bed to a 90° angle. D. Remove the dressing to inspect the wound.

Correct Answer is B

Explanation

B. This is a reasonable action given the client's respiratory rate and potential hypoxemia resulting from the sucking chest wound. Providing supplemental oxygen can help improve oxygenation and support the client's respiratory effort. However, it doesn't directly address the underlying cause of the shock.

A. In this scenario, the client's vital signs indicate signs of shock, which could be due to significant blood loss from the sucking chest wound. While inserting a central line may be necessary for administering fluids and medications rapidly, it's not the immediate priority in this situation. Stabilizing the client's condition takes precedence.

C. Elevating the foot of the bed to a 90° angle is not appropriate in this situation. This position can further decrease venous return to the heart, potentially exacerbating the client's hypotension and shock. It's crucial to maintain a neutral or slightly elevated position to optimize venous return.

D. While it's important to assess the wound and monitor for any changes, removing the dressing on a sucking chest wound without appropriate precautions can worsen the client's condition. The dressing helps to maintain a seal over the wound, preventing further air from entering the pleural space and worsening the tension pneumothorax. Removing the dressing should be done cautiously and preferably by a healthcare provider trained in managing chest trauma.

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A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

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Naxlex Comprehensive Predictor Exams

Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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