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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bilateral coarse, crackle breath sounds: These are common findings in pulmonary edema due to fluid accumulation in the lungs. Furosemide, a diuretic, helps reduce fluid overload, making it an appropriate medication to help improve these symptoms by promoting diuresis.
B. Vesicular breath sounds over the peripheral lung fields: Vesicular breath sounds are normal, and do not indicate the need for diuretics. The prescription for furosemide would be more appropriate if the client had signs of fluid overload, such as crackles.
C. Potassium 3.2 mEq/L (3.5 mEq/L to 5.0 mEq/L): This indicates hypokalemia. Since furosemide can cause potassium depletion, the nurse should verify the prescription and monitor the client’s potassium levels closely, as additional supplementation may be needed.
D. Blood pressure 100/70 mm Hg: This blood pressure is on the lower side of normal. While furosemide can lower blood pressure, this finding alone doesn't specifically indicate that the pulmonary edema is being effectively treated.
Correct Answer is B
Explanation
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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