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HESI RN Med Surg 3 Questions

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Question 1 of 5

The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

Correct Answer: A

Rationale: A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Similar Questions

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After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?

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