A nurse is caring for a client following a synchronized cardioversion. Which of the following findings indicates a therapeutic response to the treatment?
Weak peripheral pulses on palpation.
Cardiac monitor indicates sinus rhythm.
Diminished breath sounds on auscultation.
Pacer spikes precede the QRS complex on the ECG tracing.
The Correct Answer is B
Rationale:
A. Weak peripheral pulses on palpation: Weak peripheral pulses can indicate poor circulation or low cardiac output, which is not a therapeutic response to synchronized cardioversion. The goal is to restore a normal rhythm and improve perfusion.
B. Cardiac monitor indicates sinus rhythm: Sinus rhythm on the cardiac monitor indicates that the cardioversion was successful in restoring a normal heart rhythm, making this the therapeutic response. This is the desired outcome after synchronized cardioversion.
C. Diminished breath sounds on auscultation: Diminished breath sounds are more indicative of respiratory issues, such as fluid in the lungs or atelectasis, and are not related to the effectiveness of synchronized cardioversion.
D. Pacer spikes precede the QRS complex on the ECG tracing: Pacer spikes are seen in patients with a pacemaker, not typically following synchronized cardioversion. If pacer spikes are seen, it indicates that pacing is occurring, which may be necessary in some situations, but it is not a sign of the success of cardioversion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Friction rub: A friction rub is a sound heard on auscultation, typically due to the rubbing of the pleurae, and is more associated with pleuritis or pleural effusion rather than respiratory failure.
B. Xerostomia: Xerostomia, or dry mouth, can be a side effect of medications or dehydration but is not directly an indication of respiratory failure.
C. Agitation: Agitation is a common early sign of respiratory failure. As oxygen levels decrease or carbon dioxide levels increase in the bloodstream, the body may respond with restlessness or agitation due to insufficient oxygenation to the brain.
D. Decreased end-tidal CO2: A decreased end-tidal CO2 can indicate poor ventilation or respiratory distress, but it is not as specific as agitation in signaling respiratory failure. Agitation is a more direct response to inadequate gas exchange.
Correct Answer is B
Explanation
Rationale:
A. Apply a sequential compression device: A sequential compression device (SCD) is used to prevent deep vein thrombosis (DVT), not foot drop. It does not provide the necessary support for preventing foot drop, which results from muscle weakness or paralysis after a CVA.
B. Use padded splints: Padded splints help maintain the foot in a neutral position, which is essential in preventing foot drop. Foot drop occurs due to weakness of the dorsiflexor muscles, and splints can prevent the foot from falling into an abnormal position, reducing the risk of deformities.
C. Elevate the extremity above the heart: Elevating the extremity above the heart is typically done to reduce edema, not to prevent foot drop. While elevating the limb can help with swelling, it does not address the muscle weakness that causes foot drop in post-CVA patients.
D. Reposition the client every 2 hr: Repositioning the client every 2 hours is important for preventing pressure ulcers and promoting circulation. However, it is does not prevent foot drop, which requires targeted interventions such as splints or exercises to maintain proper foot positioning.
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