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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

Monitoring a client after a transesophageal echocardiogram involves observing the client for any immediate post-procedure complications or adverse reactions. This may include assessing vital signs, monitoring for signs of bleeding or infection, and reporting any concerning symptoms or changes in the client's condition to the nurse.

Checking the client's catheter site after a coronary angiogram requires assessing the site for bleeding, hematoma, or signs of infection. This task involves more complex assessment skills and would typically be performed by the nurse.

Teaching a patient about exercise electrocardiography involves providing education on the purpose of the test, the procedure itself, and any preparation or precautions the patient needs to take. This task requires specialized knowledge and is best performed by the nurse who can address the patient's specific questions and concerns.

Attaching ECG monitoring electrodes after a patient bathes requires technical knowledge and skill in properly placing the electrodes and ensuring accurate ECG readings. This task also falls within the scope of the nurse's responsibilities.

Delegation should be based on the UAP's skill set, training, and the complexity of the task. While the UAP can provide valuable support in monitoring a client after a transesophageal echocardiogram, the other tasks mentioned require the expertise and knowledge of a nurse.

A. Maintaining a low-potassium diet B. Skipping a medication dose if dizziness occurs C. Maintaining a 2 gram-sodium diet D. Drink three glasses of wine a day

Correct Answer is C

Explanation

Maintaining a 2 gram-sodium (salt) diet is an important aspect of managing hypertension. High sodium intake can contribute to elevated blood pressure. Therefore, reducing sodium intake is recommended to help control blood pressure levels. The nurse should provide guidance on reading food labels, avoiding high-sodium processed foods, and incorporating a diet rich in fruits, vegetables, and whole grains.

The other options listed are not appropriate or beneficial for managing hypertension:

Maintaining a low-potassium diet: Potassium is an essential mineral that helps regulate blood pressure. While specific potassium restrictions may be necessary for some individuals with certain medical conditions, most people with hypertension do not need to limit their potassium intake. In fact, a balanced diet with adequate potassium is generally recommended.

Skipping a medication dose if dizziness occurs: It is not advisable to skip medication doses without consulting a healthcare provider. Hypertension medications are prescribed to help control blood pressure, and missing doses can lead to uncontrolled hypertension and potential complications. If the client experiences dizziness or other side effects from the medication, they should consult their healthcare provider for appropriate management.

Drinking three glasses of wine a day: Excessive alcohol consumption can contribute to elevated blood pressure. The recommended alcohol intake for individuals with hypertension is moderate or limited to moderate levels, which typically means no more than one drink per day for women and two drinks per day for men. Drinking excessive amounts of wine or any alcoholic beverage can negatively affect blood pressure control.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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