A nurse is caring for a client who is found unresponsive and pulseless in their room. An ECG confirms the client is in pulseless ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Defibrillation

Vagal maneuvers

Radiofrequency catheter ablation

Administration of Atropine

Answer and Explanation

The Correct Answer is A

Choice A reason: Defibrillation is the appropriate intervention for pulseless ventricular tachycardia (VT). It delivers an electrical shock to the heart to restore a normal rhythm. Immediate defibrillation is crucial for survival as it can terminate the arrhythmia and allow the heart to re-establish an effective rhythm.

Choice B reason: Vagal maneuvers, such as the Valsalva maneuver, are used to terminate supraventricular tachycardias but are ineffective for pulseless VT. These maneuvers stimulate the vagus nerve to slow the heart rate but do not provide the necessary intervention for life-threatening arrhythmias like pulseless VT.

Choice C reason: Radiofrequency catheter ablation is a procedure used to treat recurrent arrhythmias by destroying abnormal electrical pathways in the heart. It is not an emergency intervention for pulseless VT. Defibrillation is needed to address the immediate, life-threatening situation.

Choice D reason: Administration of atropine is not indicated for pulseless VT. Atropine is used to treat bradycardia by increasing heart rate, but it does not address the underlying cause of VT. Defibrillation is the correct immediate intervention for pulseless VT.

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Correct Answer is C

Explanation

Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.

Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.

Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.

Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.

A. Dilated pupils B. Hyperactive bowel sounds C. Hyperglycemia D. Positive Chvostek's sign

Correct Answer is D

Explanation

Choice A reason: Dilated pupils are not a clinical manifestation of hypocalcemia. Hypocalcemia primarily affects the neuromuscular system, leading to symptoms such as muscle cramps and tetany. Pupillary changes are not commonly associated with low calcium levels.

Choice B reason: Hyperactive bowel sounds are not typically associated with hypocalcemia. While hypocalcemia can lead to muscle spasms and cramps, it does not usually cause changes in gastrointestinal motility. Hyperactive bowel sounds may be related to other gastrointestinal disorders.

Choice C reason: Hyperglycemia is not a clinical manifestation of hypocalcemia. Hypocalcemia affects calcium levels in the blood and neuromuscular function. Hyperglycemia is related to elevated blood sugar levels and is not directly connected to calcium metabolism.

Choice D reason: Positive Chvostek's sign is a clinical manifestation of hypocalcemia. This sign is elicited by tapping on the facial nerve, causing twitching of the facial muscles. It is an indication of neuromuscular irritability due to low calcium levels.

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A nurse is caring for a client who is found unresponsive and pulseless in their room. An ECG confirms the client is in pulseless ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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