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 C

Explanation

A. This test set is incomplete for diagnosing DIC. While PT and fibrinogen are important, the eosinophil count is not a key test for DIC.
B. While fibrin degradation products are useful, lactic acid is not specific for DIC and may indicate other issues. A complete blood count is helpful but not definitive for diagnosing DIC.
C. These are key markers for DIC. An elevated D-dimer indicates clot formation and breakdown, while fibrinogen and fibrin degradation products are used to assess clotting and fibrinolysis, both of which are abnormal in DIC.
D. Complete blood count, complete metabolic panel, and prothrombin time are general tests and can give some clues, but they are not definitive for diagnosing DIC.

A. Consume 2500mL of fluids per day during the summer months B. Maintain daily sodium intake of no more than 2gm per day C. Notify the health care provider if weight increases by 5 Ibs. in one week D. If shortness of breath occurs with minimal activity, notify the provider E. Take furosemide anytime when feeling bloated or short of breath

Correct Answer is ["B","C","D"]

Explanation

A. Fluid intake may need to be regulated in heart failure patients, consuming 2500mL of fluids per day may be too high for some patients, depending on their condition and whether they are on fluid restriction. Fluid management should be individualized, and the provider should specify the amount based on the patient's condition.
B. A low-sodium diet is essential for heart failure patients to help reduce fluid retention, decrease blood pressure, and lessen the burden on the heart. The American Heart Association recommends a sodium intake of no more than 2,000-2,300 mg per day for heart failure patients.
C. Rapid weight gain is a sign of fluid retention, which can indicate worsening heart failure. A gain of 2-3 pounds in a single day or 5 pounds in a week should prompt the client to contact their healthcare provider for further evaluation.
D. Shortness of breath with minimal activity can be a sign of worsening heart failure or fluid overload. This symptom should be reported immediately to a healthcare provider for further evaluation and possible adjustments to treatment.
E. Furosemide (a diuretic) is often prescribed to reduce fluid retention but it should not be taken without proper guidance or as a response to symptoms without consulting the healthcare provider. Taking diuretics at the wrong time or in excessive amounts can lead to dehydration and electrolyte imbalances, which could worsen the condition.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["B","C","D"]

Explanation

Labs

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The nurse recognizes that which laboratory test order set will guide the provider to a diagnosis of DIC?

Correct Answer is C

Explanation

The nurse is providing discharge instructions for the client diagnosed with heart failure. Which information should the nurse provide to assist the client to limit complications and prevent future hospitalizations? (SELECT ALL THAT APPLY).

Correct Answer is ["B","C","D"]

Explanation

The nurse is caring for a client who received a transfusion of Fresh Frozen Plasma (FFP) for an acute GI bleed related to accidental wantarin overdose. Which laboratory result would indicate the need for an additional unit of Fresh Frozen Plasma (FFP) to correct the problem caused by the overdose?

Labs

The nurse is planning care for a client diagnosed with heart failure who will soon be discharged home. What should be included in the teaching plan? The client will:

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?

When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

The nurse is caring for a client in the coronary care unit and the monitor depicts the rhythm shown below. What is the nurse’s interpretation of this rhythm?

A patient is to receive a continuous infusion of Diltiazem at 5 mg/hr for Atrial fibrillation. The medication is supplied 125 mg of Diltiazem in 125 mL of Iv fluid. At what rate should the nurse set the IV pump? (round to the nearest whole number)

The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV. Which parameter would the nurse use to best evaluate if the client is responding to this medication?