A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure.
The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.
Administer O2 to maintain oxygen saturation greater than 90%.
Prepare the client for intubation.
Apply continuous ECG monitoring.
Obtain the client’s family history.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}
Rationales:
- Administer O2 to maintain oxygen saturation greater than 90%: This prescription is indicated. Hypoxia can exacerbate cardiac and respiratory issues, so it is essential to maintain adequate oxygen levels in the blood. Supplemental oxygen can help improve tissue oxygenation and reduce strain on the heart.
- Apply continuous ECG monitoring: This prescription is indicated. Continuous ECG monitoring is crucial in detecting arrhythmias and ischemic changes in a patient with cardiac symptoms and irregular pulse. Early detection allows for timely intervention and management of potentially life-threatening cardiac events.
- Obtain the client’s family history: This prescription is nonessential. While obtaining a family history is useful for identifying potential genetic predispositions to cardiac and metabolic conditions, it is not immediately necessary for the acute management of the client’s current symptoms.
- Prepare the client for intubation: This prescription is contraindicated. The client is currently maintaining an adequate respiratory rate and oxygen saturation on room air. There is no indication of respiratory failure or inability to maintain airway patency. Intubation would be an unnecessarily invasive procedure at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The PR interval on an ECG represents the time from the onset of atrial depolarization to the onset of ventricular depolarization. It does not measure ventricular depolarization and repolarization.
Choice B rationale
The QT interval measures the total time taken for both ventricular depolarization and repolarization. Normal QT interval ranges are typically 350 to 440 milliseconds, depending on heart rate.
Choice C rationale
The QRS complex represents the duration of ventricular depolarization but does not include the repolarization phase. The normal duration of the QRS complex is usually 0.06 to 0.10 seconds.
Choice D rationale
The ST segment represents the time during which the ventricles are depolarized. It does not measure the time taken for ventricular depolarization and repolarization, but it can indicate ischemia or infarction. .
Correct Answer is B
Explanation
Choice A rationale
Placing the patient in a left lateral position may not address the root cause of rapid, erratic electrical impulses. It stabilizes the airway but doesn't resolve the arrhythmia.
Choice B rationale
Initiating CPR and preparing for defibrillation are crucial. Rapid, erratic impulses suggest ventricular fibrillation, needing immediate CPR and defibrillation for survival.
Choice C rationale
Administering Furosemide, a diuretic, targets fluid overload but doesn't treat rapid, erratic electrical impulses like ventricular fibrillation, requiring immediate resuscitation.
Choice D rationale
A thorough assessment delays urgent intervention for life-threatening arrhythmias like ventricular fibrillation. Immediate CPR and defibrillation are essential for patient survival.
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