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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hydrochlorothiazide is a diuretic medication commonly prescribed for hypertension. It works by increasing urine output, which helps to reduce fluid volume and lower blood pressure. Taking the medication in the morning is beneficial because the increased urine production during the day can help prevent nighttime disruptions due to frequent urination.
Let's go through the other statements and explain why they are not accurate:
"I will not take this medicine when my blood pressure is okay":
This statement indicates a misunderstanding about the purpose of hydrochlorothiazide. It is important to take prescribed medications consistently, even when blood pressure readings are within the normal range, as they are intended to help maintain blood pressure control.
"I will check blood pressure in both arms and legs before taking the drug":
Checking blood pressure in both arms and legs is not directly related to hydrochlorothiazide use. Blood pressure should be monitored regularly, but it is not necessary to perform these measurements specifically before taking the medication.
"I will decrease potassium foods such as bananas in my diet":
Hydrochlorothiazide can cause potassium loss as a side effect. However, reducing potassium-rich foods without healthcare provider guidance may not be appropriate. It is important for the client to discuss dietary adjustments and potassium supplementation with their healthcare provider if needed.
Correct Answer is A
Explanation
The information that the nurse should include in the teaching plan for a client with hypertension who is on alpha blockers and at risk for postural hypotension is: Change positions slowly.
Alpha blockers are a class of medications commonly prescribed for hypertension. One potential side effect of alpha blockers is postural hypotension, which is a sudden drop in blood pressure when changing positions, such as from sitting to standing. To minimize the risk of postural hypotension, it is important for the client to change positions slowly. The nurse should advise the client to take their time when transitioning from lying down, sitting, or standing, allowing their body to adjust and stabilize their blood pressure.
The other options are not appropriate or helpful in managing postural hypotension:
Check blood pressure every day for signs of rebound hypertension: Rebound hypertension refers to a sudden increase in blood pressure that can occur when discontinuing certain antihypertensive medications. It is not directly related to postural hypotension. Regular blood pressure monitoring is important for managing hypertension, but it is not specifically related to postural hypotension or alpha blockers.
Do not become dependent on canes, walkers, or handrails: Assistive devices like canes, walkers, or handrails can provide support and stability for individuals who experience balance issues or are at risk of falls. It is not necessary to discourage their use unless there are specific contraindications or safety concerns.
Eat plenty of salty food to prevent hypotension: Increasing salt intake is generally not recommended for individuals with hypertension or those at risk of postural hypotension. A high-sodium diet can contribute to elevated blood pressure and is generally discouraged. The nurse should instead encourage a balanced diet that includes appropriate sodium intake based on the client's healthcare provider's recommendations.
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