The nurse is caring for a client with a temporary pacemaker. The client's bedside monitor shows a spike followed by a QRS complex. What is the nurse's best action?
a. Remove the pacemaker; it is not needed.
b. Decrease the threshold of the pacemaker.
c. Document the finding in the client's chart.
d. Set the pacemaker to the synchronous mode.
C
A spike followed by a QRS complex indicates "capture," meaning that the pacemaker has suc-cessfully depolarized or captured the ventricle. No action other than documentation of this find-ing is necessary.
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In counseling a teenage client who has decided to relinquish her baby for adoption, the nurse should:
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An older patient with a history of constipation has been directed to use an over-the-counter medication to help manage symptoms of gastroesophageal reflux by buffering the gastric pH. Which medication would be the best for the patient to use?
1. Pepcid 2. Maalox 3. Mylanta 4. Milk of Magnesia
A nurse is discussing the role of a vector in the spread of disease. Which of the following is the nurse most likely referring to?
a. Contaminated water b. A tick c. A dirty needle d. An infected person
During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be?
1. To help the fetal head descend faster 2. To use gravity and manipulation to relieve compression on the cord 3. To facilitate dilation of the cervix with prostaglandin gel 4. To prevent head compression