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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
Encouraging exercise to increase heart rate in a patient with myocardial ischemia could potentially worsen the condition. Exercise increases the demand for oxygen in the heart, which may not be met due to the reduced blood flow in ischemia, potentially leading to further damage.
Choice B rationale
Administering a diuretic to decrease volume is not the most beneficial intervention for a patient with myocardial ischemia. While diuretics can reduce the workload of the heart by decreasing blood volume, they do not directly address the issue of reduced blood flow to the heart muscle that characterizes ischemia.
Choice C rationale
Giving an antibiotic to decrease infection is not relevant in this context. Myocardial ischemia is not caused by an infection, but by a reduction in blood flow to the heart muscle, often due to a blockage in one or more of the coronary arteries.
Choice D rationale
Applying oxygen to increase myocardial oxygen supply is the most beneficial intervention for a patient with myocardial ischemia. Oxygen therapy can help to meet the oxygen demand of the heart muscle when blood flow is reduced, alleviating symptoms and preventing further damage.

A. Calcium channel blocker B. Phosphodiesterase 5 enzyme inhibitor C. Anticoagulant D. Loop diuretics

Correct Answer is B

Explanation

Choice A rationale
Calcium channel blockers are primarily used to treat hypertension, angina, and certain heart arrhythmias. They work by relaxing the muscles of your heart and blood vessels. While they can affect heart rate and blood pressure, they would not typically have immediate implications for a patient presenting with intermittent chest pain.
Choice B rationale
Phosphodiesterase 5 enzyme inhibitors, such as sildenafil (Viagra), are used to treat erectile dysfunction and pulmonary arterial hypertension. These medications can interact with nitroglycerin, a common medication used to treat chest pain, to cause a severe and life-threatening drop in blood pressure. Therefore, it’s crucial to know if a patient is taking this type of medication when they present with chest pain.
Choice C rationale
Anticoagulants are used to prevent blood clots. If a patient is taking an anticoagulant, it could affect their clotting times and could be important if the patient needs surgery or if the cause of their chest pain is a clot. However, this would not typically have immediate implications for the treatment of chest pain.
Choice D rationale
Loop diuretics are strong diuretics that are used to treat edema and hypertension. They work by preventing your body from absorbing too much salt, allowing the salt to instead be passed in your urine. While important to know for overall patient care, they would not typically have immediate implications for a patient presenting with chest pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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?