A nurse is monitoring a client's heart rhythm following the insertion of a permanent pacemaker.

Which of the following images should the nurse expect?

A regular sinus rhythm.

A chaotic, irregular rhythm.

Absence of any electrical activity.

A series of spikes followed by a QRS complex.

Answer and Explanation

The Correct Answer is D

A pacemaker sends electrical signals to the heart to regulate the heartbeat.
On an electrocardiogram (ECG), these signals appear as small spikes followed by a QRS complex, which represents the contraction of the ventricles.
Choice A, A regular sinus rhythm, is not the correct answer because a regular sinus rhythm is a normal heart rhythm that originates from the sinoatrial (SA) node and does not involve a pacemaker.
Choice B, A chaotic, irregular rhythm, is not the correct answer because a pacemaker is designed to regulate the heartbeat and prevent chaotic or irregular rhythms.
Choice C, the Absence of any electrical activity, is not the correct answer because a pacemaker sends electrical signals to the heart to regulate its activity.

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Correct Answer is A

Explanation

A decrease in the Glasgow Coma Scale (GCS) score indicates a decline in the client’s level of consciousness and neurological function.
This can be a sign of increased intracranial pressure or other complications related to the skull fracture.
Choice B is incorrect because an increase in WBC count may indicate an infection, but it is not as concerning as a decrease in GCS score.
Choice C is incorrect because a change in pulse pressure may indicate changes in cardiovascular function, but it is not as concerning as a decrease in GCS score.
Choice D is incorrect because a change in pupil diameter may indicate changes in neurological function, but it is not as concerning as a decrease in GCS score.

A. Obtain a WBC count with differential. B. Obtain a blood specimen for culture and sensitivity testing. C. Obtain a history to determine recent injuries. D. Obtain a broad-spectrum antibiotic for rapid administration.

Correct Answer is B

Explanation

The priority action for a nurse caring for an older adult client who is suspected of having septicemia is to obtain a blood specimen for culture and sensitivity testing.
This test will help identify the specific microorganism causing the infection and determine the most effective antibiotic treatment.
Choice A is incorrect because while a WBC count with differential can provide information about the presence of an infection, it does not identify the specific microorganism causing the infection.
Choice C is incorrect because while obtaining a history to determine recent injuries can provide useful information, it is not the priority action.
Choice D is incorrect because while administering a broad-spectrum antibiotic may be necessary, it should not be done before obtaining a blood specimen for culture and sensitivity testing.

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A nurse is monitoring a client's heart rhythm following the insertion of a permanent pacemaker. Which of the following images should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who is suspected of having septicemia. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

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A nurse is monitoring a client's heart rhythm following the insertion of a permanent pacemaker.

Which of the following images should the nurse expect?