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The nurse is caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply

Pacer spikes are adequate in number.

Pacer spikes occur directly before the P waves.

Pacer spikes occur directly before the QRS waves.

Pacer spikes occur on the T waves.

The heart rate is within programmed parameters.

Answer and Explanation

Correct Answer : D,E

The traces that should require immediate follow-up by the nurse are:

● Pacer spikes occur directly before the T waves.

Pacer spikes occurring on the T waves indicate an issue with the pacemaker's timing or sensing. This could lead to inappropriate pacing or pacing during the refractory period, which can be detrimental to the client's heart function.

● The heart rate is outside of programmed parameters.

If the heart rate is outside of the programmed parameters set for the client's pacemaker, it may indicate a malfunction or failure of the device or a change in the client's cardiac status. It is important for the nurse to assess the client's condition and notify the healthcare provider for further evaluation and intervention.

Let's review the other options and explain why they do not require immediate follow-up:

Pacer spikes are adequate in number: This indicates that the pacemaker is delivering the appropriate number of electrical impulses as programmed. As long as the other parameters are normal, this finding does not require immediate follow-up.

Pacer spikes occur directly before the P waves: This is the desired and expected pattern for a pacemaker in normal sinus rhythm. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

Pacer spikes occur directly before the QRS waves: This is also the desired and expected pattern for a pacemaker in clients with ventricular pacing. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

The heart rate is within programmed parameters: If the heart rate falls within the programmed parameters set for the client's pacemaker, it indicates that the device is functioning appropriately in maintaining the desired heart rate.

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Correct Answer is ["A","C","D","E"]

Explanation

The questions related to the client's history that are most important to ask are:

How would you describe your symptoms?: This question is important to assess the client's current cardiac symptoms and determine the severity, duration, and nature of their symptoms. It helps the nurse to evaluate the client's cardiac status and determine appropriate interventions.

Are you allergic to any medications or foods?: This question is crucial to identify any potential allergies that could impact the client's cardiac care. It helps the nurse ensure that medications and interventions are safe for the client and prevent any adverse reactions.

How did your mother die?:This question is important to gather information about the client's family history of cardiac diseases and potential risk factors. Understanding the family history helps the nurse assess the client's genetic predisposition to cardiac conditions and plan appropriate interventions and screenings.

Have you had shortness of breath or weight gain? : This question is important to assess for symptoms of heart failure or fluid retention. Shortness of breath and weight gain can indicate fluid accumulation, which is a common symptom in cardiac conditions. It helps the nurse evaluate the client's cardiac function and determine the need for furtherinterventions or medication adjustments.

Let's review the other options and explain why they are not the most important questions to ask:

Do you have any children?: While family history is important, specifically asking about children is not as relevant to the client's current cardiac condition. The focus should be on the client's own symptoms, medical history, and family history of cardiac diseases.

A. Elevate the legs and arms above the heart when resting. B. Encourage the client to engage in a moderate amount of exercise. C. Encourage extended periods of sitting or standing. D. Discourage walking in order to limit pain.

Correct Answer is B

Explanation

The most appropriate intervention for a client diagnosed with peripheral arterial insufficiency is: Encourage the client to engage in a moderate amount of exercise. Peripheral arterial insufficiency is a condition characterized by reduced blood flow to the extremities, typically the legs, due to narrowed or blocked arteries. Regular exercise is an important component of managing peripheral arterial insufficiency. Exercise helps improve circulation, promote collateral blood vessel development, and increase the distance a client can walk before experiencing pain (intermittent claudication). Therefore, encouraging the client to engage in a moderate amount of exercise, such as walking, under healthcare provider guidance is crucial.]

The other options are not appropriate interventions for peripheral arterial insufficiency:

Elevating the legs and arms above the heart when resting: While elevation can be beneficial for certain conditions, such as reducing swelling in venous insufficiency, it is not the primary intervention for peripheral arterial insufficiency. Elevation alone does not improve arterial blood flow and may not effectively address the underlying circulatory issues.

Encouraging extended periods of sitting or standing: Prolonged sitting or standing can further restrict blood flow and exacerbate symptoms in clients with peripheral arterial insufficiency. Encouraging regular movement and avoiding prolonged immobility is important to maintain adequate circulation.

Discouraging walking in order to limit pain: While walking may cause pain or discomfort in clients with peripheral arterial insufficiency (intermittent claudication), it is important to encourage walking as part of an exercise regimen. Walking helps improve symptoms over time and promotes overall cardiovascular health.

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The nurse is caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is interviewing a client with a complex cardiac history. Which questions related to the client's history are most important to ask? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?

Correct Answer is B

Explanation

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