A nurse is caring for a client following a synchronized cardioversion. Which of the following findings indicates a therapeutic response to the treatment?

Diminished breath sounds on auscultation

Weak peripheral pulses on palpation.

Pacer spikes precede the QRS complex on the ECG tracing.

Cardiac monitor indicates sinus rhythm

Answer and Explanation

The Correct Answer is D

A. Diminished breath sounds on auscultation: Diminished breath sounds may indicate pulmonary complications such as atelectasis or fluid accumulation, which are not related to the effectiveness of cardioversion. This finding does not reflect a therapeutic response.

B. Weak peripheral pulses on palpation: Weak pulses suggest poor perfusion or ongoing cardiac dysfunction rather than successful cardioversion. A therapeutic response would improve cardiac output and perfusion, resulting in stronger, more palpable pulses.

C. Pacer spikes precede the QRS complex on the ECG tracing: Pacer spikes indicate the presence of a pacemaker delivering electrical impulses, not the success of synchronized cardioversion. Cardioversion effectiveness is measured by the restoration of normal rhythm rather than pacemaker activity.

D. Cardiac monitor indicates sinus rhythm: Restoration of sinus rhythm on the cardiac monitor demonstrates that the synchronized cardioversion successfully terminated the dysrhythmia. Achieving sinus rhythm indicates improved electrical conduction and is the primary therapeutic goal of the procedure.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ensure one finger can be inserted between the vest and client's skin: Allowing one finger’s space prevents skin breakdown while maintaining proper immobilization. This ensures the vest is snug enough to stabilize the cervical spine but not so tight that it causes pressure ulcers or discomfort.

B. Use the halo device to turn the client in bed: The halo device is rigid and should never be used as a lever to move the client, as this can cause cervical spine injury. Turning and repositioning should be done by supporting the head, neck, and torso manually, not by pulling on the device.

C. Use a pen to itch under the vest: Inserting objects under the vest can damage the skin and increase the risk of infection or pressure injuries. Clients should be taught to relieve itching by gentle tapping or using approved tools outside the vest.

D. Tighten halo pins when loose: Halo pins should only be adjusted by a healthcare provider. Tightening pins independently can cause skull fractures, nerve injury, or increased pain, making this action unsafe for nursing practice.

A. "Perform CPR while the AED is analysing” B. "Use an AED for a client who has atrial fibrillation." C. "Position the client on a flat surface.” D. "Set the AED to 80 joules."

Correct Answer is C

Explanation

A. "Perform CPR while the AED is analyzing": The AED must analyze the heart rhythm without interference. Performing CPR during analysis can prevent the device from accurately detecting a shockable rhythm, so the nurse should instruct to pause CPR while the AED evaluates the client.

B. "Use an AED for a client who has atrial fibrillation.": AEDs are not indicated for atrial fibrillation unless it degenerates into a pulseless ventricular arrhythmia. AEDs are designed for sudden cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia, not for non-life-threatening arrhythmias.

C. "Position the client on a flat surface.": Placing the client on a firm, flat surface ensures effective chest compressions and proper contact of AED pads with the chest. This positioning is critical for both CPR efficacy and accurate AED analysis.

D. "Set the AED to 80 joules.": Modern AEDs are automatic and preprogrammed to deliver the appropriate energy level. Users should not manually set joules, as the device determines the correct shock dose for safety and effectiveness.

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A nurse is caring for a client following a synchronized cardioversion. Which of the following findings indicates a therapeutic response to the treatment?

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