A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Perform carotid massage on the client

Administer adenosine 12mg IV push STAT

Prepare the client for electrical cardioversion

Assess patient and obtain vital signs

Answer and Explanation

The Correct Answer is D

A.   Carotid massage can be used as a vagal maneuver for certain types of supraventricular tachycardia (SVT), particularly in stable patients. However, it is not recommended in cases where the patient has a history of cocaine use or is showing signs of instability because of the potential for triggering a serious event, like a stroke.
B.   Adenosine is a medication commonly used for the treatment of SVT. However, it should be given with caution and only after assessing the patient's condition. In this case, the patient needs to be assessed first, including vital signs, level of consciousness, and overall stability, before any medications are administered.
C.   Electrical cardioversion is indicated for unstable SVT (e.g., signs of hemodynamic instability such as hypotension, chest pain, or altered mental status). However, this patient is only reporting a "racing heart" and nervousness and has not yet been assessed for vital signs or other clinical symptoms.
D.   The first step in this case should be to assess the patient's condition. This includes checking the vital signs, level of consciousness, and overall stability. Once this initial assessment is performed, the nurse can then determine whether medications or other interventions (like adenosine or cardioversion) are needed.

Nursing Test Bank

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Correct Answer is D

Explanation

A. The 20-gauge catheter in the right wrist is not ideal for blood transfusions, as wrist veins are smaller and may be less optimal for high-flow transfusions.
B. An 18-gauge catheter is appropriate for blood transfusions, but the catheter is currently in use for potassium chloride, which would need to be discontinued. The best choice is a separate site.
C. A 22-gauge catheter is not large enough for blood transfusion; it may cause hemolysis or slow the transfusion rate.
D. The 20-gauge catheter in the right forearm is an appropriate size for a blood transfusion and is currently infusing normal saline, which does not interfere with the blood transfusion.

A. count the number of large squares in the R-R interval and divide by 30C B. print a 1-minute ECG strip and count the number of ORS complexes, C. count the number of QRS complexes in 6 seconds and multiply by 10. D. calculate the number of small squares between one QRS complex and the next one and divide by 1500.

Correct Answer is C

Explanation

A. Counting the number of large squares between R-R intervals and dividing by 30 is not the correct method for estimating the ventricular rate on an ECG strip.
B. Printing a 1-minute ECG strip and counting the QRS complexes (option B) is accurate but unnecessary for a quick estimation.
C. The most common and efficient method for estimating the ventricular rate quickly is to count the number of QRS complexes in a 6-second strip (often marked by two dashed lines) and multiply by 10. This gives an estimate of the heart rate per minute.
D. Counting the number of small squares between QRS complexes and dividing by 1500 is the most accurate method but requires more time and precision than counting QRS complexes in 6 seconds.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to start a transfusion of packed red blood cells for a client with a hemoglobin of 5.4 g/dL. (normal Female: 11.7-15.5 g/dL; Male: 14-17.3 g/dL). Which IV site should the nurse use?

Correct Answer is D

Explanation

When using an ECG rhythm strip to quickly estimate the ventricular rate for a client, the nurse should:

Correct Answer is C

Explanation

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