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.

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Correct Answer is A

Explanation

A. INR = 3.7: The International Normalized Ratio (INR) is a measure of blood clotting. An INR greater than
3.0 indicates that the blood is not clotting properly, which can be caused by warfarin overdose. An elevated INR requires FFP to correct coagulopathy.
B. Hemoglobin = 6.3g/dL: This is low, indicating anemia, but it is not directly related to warfarin overdose. The primary issue here is coagulopathy, not anemia.
C. Fibrinogen = 90mg/dL: Fibrinogen levels may be decreased in various conditions, but this alone does not necessarily require additional FFP unless it’s below a critical threshold. Fibrinogen is not the main marker for warfarin overdose.
D. Platelets = 101,000 mm3: This platelet count is within the lower end of the normal range but does not indicate that more FFP is needed in response to warfarin overdose.

A. Instruct the client to remain quiet and refrain from activity B. Continue to monitor as this may occur with a transvenous pacemaker C. Assess the client's blood pressure and take an apical pulse D. Notify the healthcare provider because the pacemaker is not sensing properly

Correct Answer is D

Explanation

A. Instructing the client to remain quiet may reduce stress or activity but does not address the issue of the pacemaker not sensing properly.
B. Continuing to monitor without addressing the malfunction is inappropriate because this could lead to complications or inappropriate pacing.
C. Assessing blood pressure and pulse is important for patient safety but the priority is addressing the pacemaker's malfunction by notifying the healthcare provider.
D. The pacemaker should sense the client's intrinsic beats to avoid inappropriate pacing. If it is firing on the T wave or at inappropriate times, it indicates a sensing issue that needs to be addressed by the healthcare provider.

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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 caring for a client who received a transfusion of Fresh Frozen Plasma (FFP) for an acute GI bleed related to accidental wantarin overdose. Which laboratory result would indicate the need for an additional unit of Fresh Frozen Plasma (FFP) to correct the problem caused by the overdose?

Correct Answer is A

Explanation

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Correct Answer is D

Explanation

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