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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 D

Explanation

Hypertension, or high blood pressure, is often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it has already caused damage to target organs such as the heart, blood vessels, kidneys, or brain. It is crucial for the client to understand that even if they do not experience symptoms, untreated or poorly controlled hypertension can lead to serious complications, including heart disease, stroke, kidney problems, and more.

While dietary changes and increasing physical activity are important lifestyle modifications for managing hypertension, it is not accurate to state that most people can control their blood pressure through these measures alone. Hypertension is a complex condition influenced by multiple factors, and many individuals require additional interventions, such as medication, to effectively manage their blood pressure.

Annual blood pressure checks are indeed important to monitor the effectiveness of treatment and ensure that blood pressure remains within the target range. However, this information is secondary to the understanding that hypertension is typically asymptomatic until target organ damage occurs.

Recognizing the potential risks associated with untreated or uncontrolled hypertension can motivate the client to adhere to their treatment plan and make necessary lifestyle changes.

A. Explain that no food or drink is allowed for 4 hours before the stress test. B. Ask the client's visitor to bring some coffee from the cafeteria for the client. C. Make up a small breakfast tray from what is available on the unit. D. Offer hot tea or coffee only.

Correct Answer is A

Explanation

The best response by the nurse would be to explain that no food or drink is allowed for 4 hours before the stress test.

The reason for this restriction is that consuming food or drink can affect the accuracy of the cardiac stress test results. Eating or drinking can increase heart rate and blood pressure, potentially altering the test's interpretation. It is important for the client to have an empty stomach to ensure accurate test results.

Let's review the other options and explain why they are not the best responses:

Asking the client's visitor to bring some coffee from the cafeteria for the client: This option goes against the restriction of no food or drink before the stress test. It is important to adhere to the guidelines provided to ensure accurate test results.

Making up a small breakfast tray from what is available on the unit: Similarly, providing breakfast to the client goes against the restriction of no food before the stress test. The client should have an empty stomach for the test.

Offering hot tea or coffee only: While hot tea or coffee might be tempting for the client, it still violates the requirement of no food or drink before the stress test. The client should only be allowed to consume water during the fasting period.

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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

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