A nurse is caring for a client who is in pulseless ventricular tachycardia (V-Tach). The nurse recognizes the need for which priority intervention?
Immediate Defibrillation
Synchronized Cardioversion
Perform CPR
Repeat electrocardiogram (ECG)
The Correct Answer is A
A. Defibrillation is the priority intervention for pulseless ventricular tachycardia, as it can restore a normal rhythm. It should be performed as soon as possible.
B. Synchronized cardioversion is used for hemodynamically unstable tachyarrhythmias with a pulse, not for pulseless V-Tach.
C. CPR should be initiated if a defibrillator is not immediately available, but defibrillation is the definitive treatment.
D. Repeating an ECG does not address the immediate life-threatening situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Location of the pain is an essential component of assessing cardiac pain, as MI-related pain is often described as substernal or radiating.
B. Distribution refers to how the pain spreads, such as from the chest to the jaw, neck, back, or arms, which is common in an MI.
C. Intensity helps determine the severity of pain and is often rated on a scale from 0 to 10.
D. While identifying factors that alleviate pain is important for overall assessment, it is not a core component of the initial pain assessment for MI.
E. Onset refers to when the pain began and whether it occurred suddenly or gradually, which helps in determining the cause.
F. Radiation is a critical aspect of cardiac pain assessment, as MI pain often radiates to the left arm, jaw, or back.
Correct Answer is A
Explanation
A. Elevated troponins are the most specific and sensitive markers for myocardial injury. Troponin I and Troponin T levels rise within a few hours of an AMI and remain elevated for days, confirming cardiac damage.
B. Elevated hemoglobin is not an indicator of cardiac injury. Hemoglobin levels are used to assess oxygen-carrying capacity and anemia.
C. Elevated B-type natriuretic peptide (BNP) is a marker for heart failure, not acute myocardial infarction.
D. Elevated creatine kinase (CK), particularly CK-MB, can indicate muscle injury, including cardiac injury, but it is less specific than troponins for diagnosing AMI.
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