A client's telemetry monitor indicates the sudden onset of ventricular fibrillation (VF). Which assessment finding should the nurse anticipate?
Bounding erratic pulse.
No palpable pulse.
Thready irregular pulse.
Regularly irregular pulse.
The Correct Answer is B
Rationale:
A. Bounding erratic pulse: A bounding pulse indicates strong cardiac output, which is inconsistent with ventricular fibrillation, where the ventricles fail to pump effectively.
B. No palpable pulse: Ventricular fibrillation causes chaotic ventricular contractions, preventing effective cardiac output. As a result, the client will have no palpable pulse and will be unresponsive, making this the expected and urgent finding.
C. Thready irregular pulse: A thready, weak, or irregular pulse may occur in severe hypotension or arrhythmias, but VF typically produces no pulse at all due to lack of coordinated ventricular contraction.
D. Regularly irregular pulse: A regularly irregular pulse suggests atrial arrhythmias or other conduction abnormalities but does not correspond to the chaotic, ineffective contractions seen in VF.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Auscultate all chest fields for muffled lung sounds: While assessing for lung sounds can identify conditions like tension pneumothorax, the client is pulseless and apneic. Immediate resuscitation takes priority over further assessment of lung sounds.
B. Begin chest compressions at a rate of 120 times a minute: The client is in pulseless electrical activity (PEA), characterized by organized cardiac rhythm on the monitor without a palpable pulse or spontaneous respirations. High-quality chest compressions are the priority intervention to maintain circulation until advanced life support can be provided.
C. View the rhythm in another chest lead: While lead verification can prevent misinterpretation of rhythms, it delays critical resuscitative measures. In a pulseless client, immediate CPR takes precedence over rhythm confirmation.
D. Observe for swelling at the fracture site: Monitoring for fracture site swelling is important for orthopedic management but is not relevant to a life-threatening cardiac arrest scenario. Circulatory support must take priority to preserve life.
Correct Answer is A
Explanation
Rationale:
A. Urinary output: Low-dose dopamine primarily stimulates dopaminergic receptors in the kidneys, promoting renal perfusion and diuresis. Monitoring urine output is a direct and sensitive indicator of improved renal blood flow and an effective therapeutic response in clients with septic shock.
B. Heart sounds: While dopamine can increase heart rate and cardiac contractility, heart sounds alone do not provide a reliable measure of renal perfusion or overall therapeutic effect at low doses.
C. Pupil response: Pupil changes are associated with neurological status and are not affected by low-dose dopamine. They do not reflect hemodynamic improvement or renal perfusion in septic shock.
D. Temperature: Dopamine does not directly influence body temperature. Fever or hypothermia in septic shock reflects the underlying infection or systemic response rather than the efficacy of dopamine therapy.
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