Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Assess the incision site for signs of infection

Apply a sling to the operative arm

Remove the pacemaker leads

Monitor vital signs regularly

Encourage vigorous physical activity

Answer and Explanation

Correct Answer : A,B,D

A.   Assess the incision site for signs of infection - This is an essential nursing intervention after any surgical procedure, including pacemaker insertion, to prevent and detect early signs of infection.
B.   Apply a sling to the operative arm - This helps to limit movement and prevent dislodging of the pacemaker leads, which is important for the healing process.
C.   Remove the pacemaker leads - This is not an appropriate intervention. The pacemaker leads are left in place after insertion to ensure proper function of the pacemaker.
D.   Monitor vital signs regularly - Regular monitoring of vital signs, especially heart rate and rhythm, is important to detect any complications such as arrhythmias after pacemaker insertion.
E.   Encourage vigorous physical activity - Vigorous physical activity should be avoided initially to prevent any strain or potential damage to the pacemaker or leads. Early mobility is important, but it should be gradual and restricted.

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Correct Answer is D

Explanation

A. This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B. This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C. This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D. This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.

A. 2nd degree Mobitz Il B. Atrial flutter C. Sinus bradycardia D. 1st degree AV block

Correct Answer is D

Explanation

A. This type of AV block is characterized by a progressively lengthening PR interval until a QRS complex is dropped (a blocked beat). A PR interval of 0.28 seconds could be seen in 2nd degree Mobitz I (Wenckebach), not Mobitz II, which has a more irregular pattern of dropped beats
B. Atrial flutter: Atrial flutter is a type of arrhythmia characterized by rapid atrial rates (typically around 250-350 beats per minute) with a sawtooth pattern of P-waves. It does not relate to the PR interval, but rather the atrial rhythm.
C. Sinus bradycardia: Sinus bradycardia is characterized by a slower-than-normal heart rate (less than 60 beats per minute), but this does not affect the PR interval directly. A normal PR interval (0.12-0.20 seconds) can still be seen in sinus bradycardia, so the prolonged PR interval in this case makes sinus bradycardia less likely.
D. 1st degree AV block: In 1st degree AV block, the PR interval is consistently prolonged, usually more than 0.20 seconds, but it is still a constant, non-variable delay in the conduction between the atria and ventricles. A PR interval of 0.28 seconds (which is longer than normal but consistent) is characteristic of a first-degree AV block, making it the correct answer.

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Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

Correct Answer is D

Explanation

The nurse notes that the client's rhythm strip indicates a PR-interval of 0.28 seconds. What is the nurse's analysis of this problem?

Correct Answer is D

Explanation

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