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NurseDive Free Nursing Practice Question
A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?
A. Vasovagal bradycardia without syncope
Vasovagal bradycardia is a temporary drop in heart rate and blood pressure caused by a stimulus thattriggers the vagus nerve, such as pain, stress, or straining. It usually resolves on its own or with simple measures, such as lying down or elevating the legs.
B. Complete AV block with rates slower than 40/min
A complete AV block (also called third-degree AV block) is a type of heart block in which there is no electrical communication between the atria and ventricles. This means that the atria and ventriclesbeat independently of each other, resulting in a slow and irregular pulse. A complete AV block can cause symptoms such as dizziness, fainting, chest pain, shortness of breath, and heart failure. A permanent pacemaker is a device that sends electrical impulses to the heart to regulate its rhythm and prevent bradycardia (slow heart rate). A permanent pacemaker is indicated for clients with complete AV block and rates slower than 40/min or symptomatic bradycardia. The other options are not indications for a permanent pacemaker.
C. Sinus tachycardia with rates faster than 80/min
Sinus tachycardia is a normal increase in heart rate in response to physical or emotional stress, such as exercise, fever, or anxiety. It usually does not require treatment unless it is caused by an underlying condition or causes symptoms.
D. Asymptomatic second-degree AV block
Asymptomatic second-degree AV block is a type of heart block in which some of the electrical impulses from the atria are blocked from reaching the ventricles. It may not cause any symptoms or affect the overall heart rate. It may be benign or transient, or it may progress to a more serious type of heart block. It may require monitoring or medication, but not a permanent pacemaker unless it causes symptomatic bradycardia.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN adult medical surgical 2019 with NGN - Proctored Exam 3. Take the full exam now
Full Explanation
A complete AV block (also called third-degree AV block) is a type of heart block in which there is no electrical communication between the atria and ventricles. This means that the atria and ventricles beat independently of each other, resulting in a slow and irregular pulse. A complete AV block can cause symptoms such as dizziness, fainting, chest pain, shortness of breath, and heart failure.
A permanent pacemaker is a device that sends electrical impulses to the heart to regulate its rhythm and prevent bradycardia (slow heart rate). A permanent pacemaker is indicated for clients with complete AV block and rates slower than 40/min or symptomatic bradycardia.
The other options are not indications for a permanent pacemaker. Vasovagal bradycardia is a temporary drop in heart rate and blood pressure caused by a stimulus that triggers the vagus nerve, such as pain, stress, or straining.
It usually resolves on its own or with simple measures, such as lying down or elevating the legs. Sinus tachycardia is a normal increase in heart rate in response to physical or emotional stress, such as exercise, fever, or anxiety. It usually does not require treatment unless it is caused by an underlying condition or causes symptoms.
Asymptomatic second-degree AV block is a type of heart block in which some of the electrical impulses from the atria are blocked from reaching the ventricles. It may not cause any symptoms or affect the overall heart rate. It may be benign or transient, or it may progress to a more serious type of heart block. It may require monitoring or medication, but not a permanent pacemaker unless it causes symptomatic bradycardia.
Similar Questions
A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?
A. Respiratory acidosis
The ABG results show a low pH (acidosis), a high PaCO2 (respiratory component), and a normal HCO3 (metabolic component). This indicates respiratory acidosis, which is caused by hypoventilation and retention of carbon dioxide.
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Full Explanation
The ABG results show a low pH (acidosis), a high PaCO2 (respiratory component), and a normal HCO3 (metabolic component). This indicates respiratory acidosis, which is caused by hypoventilation and retention of carbon dioxide.
A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
A. Administer 0.9% sodium chloride.
B. Initiate a continuous IV insulin infusion.
The priority intervention for a client in DKA is to initiate a continuous IV insulin infusion to lower the blood glucose level and reverse the ketosis. Insulin also helps to correct the electrolyte imbalance and acid-base imbalance in DKA.
C. Begin bicarbonate continuous IV infusion.
D. Check potassium levels.
Full Explanation
The priority intervention for a client in DKA is to initiate a continuous IV insulin infusion to lower the blood glucose level and reverse the ketosis. Insulin also helps to correct the electrolyte imbalance and acid-base imbalance in DKA.
A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?
A. Bradycardia
B. Headache
Anemia is a condition characterized by a decrease in hemoglobin level or red blood cell count, resulting in reduced oxygen-carrying capacity of the blood. This can cause various symptoms such as fatigue, weakness, pallor, dyspnea, tachycardia, and headache.
C. Heat intolerance
D. Flushed skin color
Full Explanation
Anemia is a condition characterized by a decrease in hemoglobin level or red blood cell count, resulting in reduced oxygen-carrying capacity of the blood. This can cause various symptoms such as fatigue, weakness, pallor, dyspnea, tachycardia, and headache.