A client whose heart monitor shows sinus tachycardia, is apneic and has no palpable pulses. What action should the nurse ta next?

Start cardiopulmonary resuscitation (CPR)

Provide supplemental 02 via non-rebreather mask

Give atropine per agency dysrhythmia protocol

Perform synchronized cardioversion

Answer and Explanation

The Correct Answer is A

A. Start cardiopulmonary resuscitation (CPR): The client is apneic with no palpable pulses, indicating cardiac arrest. The immediate priority is to begin CPR to provide chest compressions and ventilation, which is essential for maintaining circulation and oxygenation.

B. Provide supplemental O2 via non-rebreather mask: While oxygen is crucial, the primary concern is restoring circulation and ensuring oxygenation through CPR. Oxygen administration alone won't address the lack of circulation, CPR should be started first.

C. Give atropine per agency dysrhythmia protocol: Atropine is typically used for bradycardia, not sinus tachycardia. The client's apneic state and lack of pulses indicate a more severe issue, such as cardiac arrest, which requires immediate CPR, not atropine.

D. Perform synchronized cardioversion: Synchronized cardioversion is used for specific arrhythmias such as atrial fibrillation or supraventricular tachycardia with a pulse. Since the client has no pulse, defibrillation (if indicated) or CPR should be initiated first, not synchronized cardioversion.

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Correct Answer is A

Explanation

Using the rule of nines for an adult:

Each leg (front and back) is 18% of TBSA (9% for the front and 9% for the back).
Each arm (front and back) is 9% of TBSA (4.5% for the front and 4.5% for the back).

Given that the client has burns on the front and back of both legs and arms:

18% (each leg) x 2 = 36%
9% (each arm) x 2 = 18%

Total TBSA = 36% (legs) + 18% (arms)

= 54%

A. CPR B. Defibrillation C. Radiofrequency catheter ablation D. Elective cardioversion

Correct Answer is B

Explanation

A. CPR: CPR is indicated if the client becomes pulseless or unresponsive, but it is not the first-line treatment for ventricular tachycardia (VT) if the client still has a pulse. In VT with a pulse, the priority is to treat the arrhythmia through defibrillation or medications, not CPR.

B. Defibrillation: Defibrillation is the most appropriate action for VT, especially if the client becomes pulseless or unstable. VT can deteriorate into ventricular fibrillation (VF), which is life-threatening. Immediate defibrillation is required to restore normal rhythm.

C. Radiofrequency catheter ablation: Radiofrequency catheter ablation is a long-term treatment option for VT, but it is not the immediate intervention for an acute episode. It is used to target and eliminate the arrhythmogenic focus after stabilization.

D. Elective cardioversion: Elective cardioversion is used for arrhythmias like atrial fibrillation or stable supraventricular tachycardias, not for life-threatening VT. In the case of VT with a pulse, if the client is unstable, defibrillation would be more appropriate.

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A client whose heart monitor shows sinus tachycardia, is apneic and has no palpable pulses. What action should the nurse ta next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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