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 D

Explanation

A. Diltiazem is a calcium channel blocker that can be used to manage conditions like atrial fibrillation or hypertension by slowing the heart rate and reducing blood pressure. However, it may not be the most appropriate drug in the acute setting for heart failure with dyspnea.
B. Nitroglycerine is a vasodilator that helps reduce preload and afterload, which can be beneficial in heart failure. However, it primarily works by reducing the workload on the heart and may help with fluid overload but may not directly address anxiety.
C. Verapamil is another calcium channel blocker that slows the heart rate and reduces the heart's workload. While it may be useful for controlling tachyarrhythmias, it is not the best option for managing acute heart failure with severe dyspnea and anxiety.
D. Morphine is an opioid that can be used in acute heart failure to reduce both anxiety and respiratory distress. It works by reducing the sympathetic nervous system response, decreasing heart rate and blood pressure, and providing a sense of calm, which reduces anxiety. It also reduces preload by venodilation and helps manage severe dyspnea.

A. Assess the incision site for signs of infection B. Apply a sling to the operative arm C. Remove the pacemaker leads D. Monitor vital signs regularly E. Encourage vigorous physical activity

Correct Answer is ["A","B","D"]

Explanation

A. Assess the incision site for signs of infection - This is an essential nursing intervention after any surgical procedure, including pacemaker insertion, to prevent and detect early signs of infection.
B. Apply a sling to the operative arm - This helps to limit movement and prevent dislodging of the pacemaker leads, which is important for the healing process.
C. Remove the pacemaker leads - This is not an appropriate intervention. The pacemaker leads are left in place after insertion to ensure proper function of the pacemaker.
D. Monitor vital signs regularly - Regular monitoring of vital signs, especially heart rate and rhythm, is important to detect any complications such as arrhythmias after pacemaker insertion.
E. Encourage vigorous physical activity - Vigorous physical activity should be avoided initially to prevent any strain or potential damage to the pacemaker or leads. Early mobility is important, but it should be gradual and restricted.

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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 caring for a client with acute heart failure who is severely dyspneic and extremely anxious. The nurse anticipates that increased cardiac output and decreased anxiety may be promoted by the IV administration of:

Correct Answer is D

Explanation

Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

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