A client admitted to the telemetry unit with a diagnosis of syncopal episodes has a sitting blood pressure of 80/50 mm Hg, a regular apical pulse, and a cardiac rhythm as shown on the monitor. The nurse should prepare the client for which procedure?

Transcutaneous pacing.

Mechanical ventilation.

Chest tube insertion.

Synchronized cardioversion.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Transcutaneous pacing: The ECG rhythm demonstrates a third-degree (complete) heart block. This results in severe bradycardia and hypotension (80/50 mm Hg), placing the client at risk for syncope and cardiac arrest. Transcutaneous pacing is the immediate intervention to maintain cardiac output until a permanent pacemaker can be placed.

B. Mechanical ventilation: Although hypotension and bradycardia can lead to hypoxia, the client’s issue is primarily electrical conduction failure, not respiratory compromise. Ventilatory support would not correct the underlying cause of hemodynamic instability.

C. Chest tube insertion: Chest tube insertion is indicated for pneumothorax or hemothorax, not cardiac conduction abnormalities. There is no evidence of respiratory distress or pleural injury requiring this intervention.

D. Synchronized cardioversion: Cardioversion is used for tachydysrhythmias such as atrial fibrillation or supraventricular tachycardia. It is contraindicated in complete heart block, where electrical pacing not shock is required to restore effective cardiac rhythm and perfusion

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Administer a benzodiazepine: Sedation may worsen respiratory drive and cause hypoventilation in a recently extubated client. Benzodiazepines should only be used if agitation persists after addressing environmental and safety concerns, and under provider direction.

B. Apply wrist restraints: The client’s confusion and attempt to climb out of bed pose a high risk for accidental self-injury or removal of oxygen equipment. Applying soft wrist restraints temporarily ensures safety while further assessing for causes of confusion and notifying the healthcare provider.

C. Notify the rapid response team: The client is hemodynamically stable with normal oxygen saturation and respiratory effort. Calling the rapid response team is unnecessary unless there is evidence of acute deterioration, such as respiratory distress or loss of consciousness.

D. Increase oxygen to 60%: The oxygen saturation of 98% indicates adequate oxygenation at the current FiO₂. Increasing oxygen unnecessarily could suppress respiratory drive and does not address the underlying cause of confusion or unsafe behavior.

A. Skeletal traction misalignment. B. Profuse forehead diaphoresis. C. An acutely distended bladder. D. A severe pounding headache.

Correct Answer is C

Explanation

Rationale:
A. Skeletal traction misalignment: While misalignment can cause discomfort and complications in spinal cord injury clients, it is not the most common or immediate trigger of autonomic dysreflexia. Assessment of alignment is secondary to more urgent causes of sympathetic overactivity.

B. Profuse forehead diaphoresis: Sweating is a symptom of autonomic dysreflexia but is a manifestation rather than a precipitating factor. Identifying the cause of the dysreflexia takes priority over treating symptoms alone.

C. An acutely distended bladder: Bladder distension is the most common precipitating factor for autonomic dysreflexia in clients with lesions at T6 or above. Immediate assessment and relief of urinary retention are critical to prevent severe hypertension, stroke, or other life-threatening complications.

D. A severe pounding headache: Headache is a classic symptom of autonomic dysreflexia, reflecting elevated blood pressure. While important to recognize, it indicates the presence of the condition rather than identifying the cause that must be addressed first.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client admitted to the telemetry unit with a diagnosis of syncopal episodes has a sitting blood pressure of 80/50 mm Hg, a regular apical pulse, and a cardiac rhythm as shown on the monitor. The nurse should prepare the client for which procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with a C-7 spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

Correct Answer is C

Explanation

An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?

A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?

Patient Data Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.

Patient Data Exhibits The healthcare provider (HCP) would like to do a thoracentesis on the client. The client's caregiver asks the nurse if there are any contraindications for the procedure. Performing a thoracentesis is contraindicated in which clinical manifestation (s)? Select all that apply.

Based on this strip, which is the correct interpretation of this rhythm?

Patient Data Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.