The nurse is caring for a client with a permanent pacemaker. The client's monitor shows a pacemaker spike prior to the p wave. What would be the nurse's best action?
Increase the pacemaker sensitivity
Document that the pacemaker is regular
Set the pacemaker to the asynchronous mode
Document that the atria are being paced
The Correct Answer is D
A. Increase the pacemaker sensitivity: Adjusting pacemaker sensitivity is a technical function typically managed by a cardiologist or device technician. There is no indication from the information provided that the pacemaker is under- or over-sensing, so no adjustment is warranted.
B. Document that the pacemaker is regular: While the pacemaker may be functioning regularly, this statement is vague and does not accurately describe the observed pacing activity. The key observation is the spike occurring before the P wave, which requires more specific documentation.
C. Set the pacemaker to the asynchronous mode: Asynchronous pacing means the pacemaker fires at a set rate regardless of the patient's intrinsic rhythm and is generally reserved for specific situations such as during surgery or when interference with sensing is suspected. There is no evidence of pacemaker malfunction or need to override sensing in this scenario.
D. Document that the atria are being paced: A pacemaker spike immediately before the P wave indicates atrial pacing. This means the pacemaker is stimulating the atria, leading to atrial depolarization. This is the appropriate interpretation and should be documented clearly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Calculate the total volume to be infused in drops.
Total drops = Total volume (mL) × Drop factor (gtts/mL)
= 1000 mL × 60 gtts/mL
= 60000 gtts
Calculate the total infusion time in minutes.
Total infusion time (minutes) = Total hours × 60 minutes/hour
= 8 hours × 60 minutes/hour
= 480 minutes
Calculate the IV flow rate in drops per minute (gtts/min).
IV rate (gtts/min) = Total drops / Total infusion time (minutes)
= 60000 gtts / 480 minutes
= 125
=125 gtts/min
Correct Answer is A
Explanation
A. Narrowed pulse pressure: Aortic stenosis leads to obstruction of blood flow from the left ventricle to the aorta during systole, reducing systolic pressure while diastolic pressure remains unchanged or slightly elevated. This results in a narrowed pulse pressure, a classic finding in moderate to severe aortic stenosis.
B. Sinus tachycardia: While tachycardia can occur in response to decreased cardiac output or stress, it is not a defining feature of aortic stenosis. The hallmark findings relate more directly to fixed cardiac output and valve obstruction.
C. Apical diastolic murmur: Aortic stenosis produces a systolic ejection murmur, best heard at the right second intercostal space and radiating to the carotids. An apical diastolic murmur would suggest mitral stenosis or other diastolic valve pathology.
D. S3 heart sound: An S3 is more indicative of volume overload and heart failure rather than valvular stenosis. While advanced aortic stenosis can lead to heart failure, the S3 is not a primary or early manifestation of this condition.
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