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 B

Explanation

A. Place the client in supine position: Placing the client in a supine position is not the first action in autonomic dysreflexia. The head should be elevated to reduce blood pressure, not placed flat. Elevating the head helps to relieve the pressure and reduce the risk of stroke.

B. Assess the client for bladder distention: Bladder distention is one of the most common triggers of autonomic dysreflexia. The nurse should first assess for any cause of discomfort, such as a full bladder or bowel impaction, which could be causing the elevated blood pressure.

C. Administer a nitrate antihypertensive: Administering antihypertensive medications may be necessary later, but first, the nurse should identify and remove the trigger of autonomic dysreflexia. Medications are not effective if the underlying cause is not addressed.

D. Obtain the client's heart rate: While it’s important to monitor the heart rate, obtaining the heart rate is not the priority in autonomic dysreflexia. The first step is to identify and relieve the cause of the elevated blood pressure to prevent further complications.

A. Respiratory rate 20/min B. Heart rate 72/min C. Blood pressure 89/50 mm Hg D. Abdominal pain rated 4 on a scale of 0 to 10

Correct Answer is C

Explanation

A. Respiratory rate 20/min: A respiratory rate of 20/min is within the normal range for an adolescent. While respiratory function should always be monitored, this finding is not alarming in the context of blunt trauma.

B. Heart rate 72/min: A heart rate of 72/min is within the normal range for an adolescent. This does not indicate immediate concern, and the patient’s heart rate is stable.

C. Blood pressure 89/50 mm Hg: A blood pressure of 89/50 mm Hg is low and indicates potential shock, which is a life-threatening concern. Hypotension following blunt abdominal trauma can suggest internal bleeding or organ injury, which requires immediate intervention.

D. Abdominal pain rated 4 on a scale of 0 to 10: While abdominal pain is a concern, a pain level of 4/10 is not immediately life-threatening. The priority is addressing the low blood pressure, which could indicate shock or internal bleeding, requiring urgent medical attention.

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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

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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