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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Endotracheal intubation and positive pressure ventilation are indicated in patients with severe respiratory failure who are unable to maintain adequate oxygenation and ventilation on their own. This intervention provides mechanical support to the patient's breathing by delivering positive pressure to the lungs via an endotracheal tube. Given the patient's respiratory rate of 6 breaths/min, low oxygen saturation (SpO2 of 78%), and increasing lethargy, endotracheal intubation and positive pressure ventilation are the most appropriate interventions to ensure adequate oxygenation and ventilation.
A. CPAP is a form of non-invasive positive pressure ventilation that helps keep the airways open and improves oxygenation. However, in a patient with severe respiratory failure and impending respiratory arrest, CPAP alone may not be sufficient to adequately support ventilation and oxygenation. CPAP is typically used in patients with milder forms of respiratory failure or as a step-down therapy from invasive mechanical ventilation.
C. Insertion of a mini-tracheostomy is not typically indicated in a patient with severe respiratory failure and impending respiratory arrest. While tracheostomy may be considered in certain cases for long-term ventilation or airway management, it is not the first-line intervention in an acute situation like this.
Additionally, frequent suctioning may not address the underlying cause of respiratory failure or improve oxygenation.
D. Administering 100% oxygen via a non-rebreather mask can help improve oxygenation temporarily. However, in a patient with severe respiratory failure and impending respiratory arrest, non-invasive oxygen therapy alone may not be sufficient to maintain adequate oxygenation and ventilation.
Endotracheal intubation and positive pressure ventilation are more definitive interventions to ensure adequate support for the patient's breathing.
Correct Answer is C
Explanation
C. Respiratory acidosis- The pH is acidic, and the PaCO2 is elevated, indicating respiratory acidosis. The client's hypoventilation (respiratory rate of 7/min) is causing retention of carbon dioxide, leading to respiratory acidosis.
A. Metabolic alkalosis- The ABG values do not support a diagnosis of metabolic alkalosis. The pH is acidic, and the base excess is negative, indicating a mild metabolic acidosis.
B. Respiratory alkalosis- The ABG values do not support a diagnosis of respiratory alkalosis. The pH is acidic, and the PaCO2 is elevated, indicating respiratory acidosis rather than alkalosis.
D. Metabolic acidosis- While there is evidence of a mild metabolic acidosis indicated by the negative base excess, the primary disturbance in this case is respiratory acidosis, as evidenced by the low pH and elevated PaCO2.
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