A nurse is caring for a client who develops third-degree heart block with a heart rate of 30/min. Which of the following actions should the nurse take?

Administer digoxin by IV bolus.

Prepare the client for temporary pacing.

Instruct the client to perform the Valsalva maneuver.

Perform carotid sinus massage.

Answer and Explanation

The Correct Answer is B

A. Administer digoxin by IV bolus: Digoxin slows conduction through the AV node and can worsen a complete heart block. It is contraindicated in this condition and may lead to further bradycardia or cardiac arrest.
B. Prepare the client for temporary pacing:Third-degree (complete) heart block results in electrical dissociation between atria and ventricles, leading to dangerously low heart rates and inadequate perfusion. The definitive treatment is temporary pacing to stabilize the cardiac rhythm until permanent pacing can be arranged.
C. Instruct the client to perform the Valsalva maneuver: This maneuver is used to terminate supraventricular tachycardias by stimulating the vagus nerve. It is not indicated in bradyarrhythmias like third-degree heart block and could further lower the heart rate.
D. Perform carotid sinus massage: This is another vagal maneuver used to treat tachycardias, not bradycardias. Performing it in a client with third-degree heart block could dangerously reduce the heart rate further and is therefore inappropriate.

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Correct Answer is D

Explanation

A. Encourage frequent visits from friends: While social interaction can be beneficial, it’s important to consider the individual’s needs and preferences. Overstimulation from too many visitors can cause anxiety or confusion, which can worsen cognitive symptoms.

B. Keep the over-the-bed light on: This may be helpful in preventing falls or confusion at night. However, it’s essential to avoid excessive lighting as it can disrupt the circadian rhythm, potentially leading to sleep disturbances. A dim nightlight is more appropriate.

C. Apply restraints to the upper extremities: Restraints should not be used as a first-line approach. They can increase confusion, anxiety, and the risk of injury. Non-restrictive interventions, such as proper positioning and a calm environment, should be prioritized.

D. Play serene, soothing music: Soothing music can be a helpful intervention to reduce anxiety, agitation, and confusion in clients with dementia. Music has been shown to have a calming effect, which can help the client feel more relaxed and at ease.

A. Place a tongue blade at the bedside. B. Dim the overhead lights. C. Assist the client to ambulate every 4 hr. D. Apply a warming blanket. E. Have suction equipment at the bedside.

Correct Answer is ["B","E"]

Explanation

A. Place a tongue blade at the bedside: Inserting an object into the mouth during a seizure can lead to airway obstruction, dental injury, or harm to the client. The focus should be on ensuring the client’s safety and airway clearance without inserting any objects.

B. Dim the overhead lights: Dim lighting can help reduce external stimuli that might trigger a seizure. Bright or harsh lights can sometimes exacerbate seizures, so it’s important to create a calm environment that helps prevent further stimulation or agitation.

C. Assist the client to ambulate every 4 hr: Ambulation is not a priority during a seizure or in the immediate post-seizure period. The client’s safety should be ensured by limiting activities that could result in injury, such as walking, especially if they are at risk for more seizures.

D. Apply a warming blanket: Applying a warming blanket is not recommended, especially in the presence of meningitis, as it can increase the risk of hyperthermia. Meningitis can already cause fever, and adding heat may worsen the condition.

E. Have suction equipment at the bedside: Suction equipment should always be available for clients experiencing seizures. This ensures that any secretions or vomit can be cleared quickly to maintain a clear airway, which is essential during and after a seizure.

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