A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
What is the first action the nurse should take?
Begin cardiopulmonary resuscitation (CPR).
Cardiovert the client with a biphasic defibrillator.
Assess airway, breathing, and circulation.
Administer an amiodarone bolus followed by a drip.
The Correct Answer is C
Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice B rationale
Cardioverting the client with a biphasic defibrillator is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice C rationale
The first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern is to assess the patient’s airway, breathing, and circulation.
Choice D rationale
Administering an amiodarone bolus followed by a drip is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While fasting may be required before certain procedures, it is not the most crucial piece of information that the nurse needs to relay to the healthcare provider prior to a cardiac catheterization and coronary angiogram.
Choice B rationale
A shellfish allergy is crucial information because the dye used in an angiogram can cause an allergic reaction in people who are allergic to shellfish.
Choice C rationale
Although a previous heart attack is significant medical history, it is not the most crucial piece of information to relay prior to this procedure.
Choice D rationale
The rating of the patient’s pedal pulses is not the most crucial piece of information to relay prior to this procedure.
Correct Answer is D
Explanation
Choice A rationale
Secondary hypertension is high blood pressure that is caused by another medical condition or medication. It is not the most common type of hypertension.
Choice B rationale
Congenital hypertension is not a recognized type of hypertension. Hypertension can be associated with some congenital conditions, but it is not a type of hypertension itself.
Choice C rationale
Acquired hypertension is not a recognized type of hypertension. While lifestyle factors can contribute to the development of hypertension, the term “acquired hypertension” is not typically used.
Choice D rationale
Primary hypertension, also known as essential hypertension, is the most common type of hypertension. It is high blood pressure that does not have a known secondary cause.
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