The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Instruct the client to remain quiet and refrain from activity

Continue to monitor as this may occur with a transvenous pacemaker

Assess the client's blood pressure and take an apical pulse

Notify the healthcare provider because the pacemaker is not sensing properly

Answer and Explanation

The Correct Answer is D

A.   Instructing the client to remain quiet may reduce stress or activity but does not address the issue of the pacemaker not sensing properly.
B.   Continuing to monitor without addressing the malfunction is inappropriate because this could lead to complications or inappropriate pacing.
C.   Assessing blood pressure and pulse is important for patient safety but the priority is addressing the pacemaker's malfunction by notifying the healthcare provider.
D.   The pacemaker should sense the client's intrinsic beats to avoid inappropriate pacing. If it is firing on the T wave or at inappropriate times, it indicates a sensing issue that needs to be addressed by the healthcare provider.

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Correct Answer is D

Explanation

A. This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B. This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C. This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D. This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.

Correct Answer is ["31"]

Explanation

(Volume to be infused (mL) × Drop factor (gtt/mL)) / Time (min).

For the patient prescribed 250 mL of packed red blood cells with a drop factor of 15 gtt/mL over 120 minutes, the calculation would be (250 mL × 15 gtt/mL) / 120 min, which equals 31.25 gtt/min.

Therefore, the nurse should regulate the IV to 31 gtt/min.

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The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

Correct Answer is D

Explanation

A patient is prescribed 250 mL of packed red blood cells to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

Correct Answer is ["31"]

Explanation

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