A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?
Elective cardioversion
CPR
Radiofrequency catheter ablation
Defibrillation
The Correct Answer is A
A. Elective cardioversion is a procedure used to restore a normal heart rhythm by delivering a controlled electrical shock to the heart. It is generally used for patients with stable atrial or ventricular arrhythmias who do not respond to medication. In the case of stable VT, elective cardioversion might be considered if the arrhythmia is causing symptoms or if the patient’s condition changes
B. CPR is an emergency procedure used when a person’s heart has stopped beating (cardiac arrest) or when they are not breathing. It is not indicated for a stable VT because the patient is still stable and conscious, and CPR is not used for arrhythmias like VT in a stable patient.
C. Radiofrequency catheter ablation is a procedure used to destroy abnormal electrical pathways in the heart that cause arrhythmias. This is often used as a treatment for recurrent or persistent VT, especially if medication or cardioversion fails to manage the condition effectively. For a stable patient with VT, this treatment might be considered in the long-term management plan rather than as an immediate intervention.
D. Defibrillation is the use of an electrical shock to the heart to restore a normal rhythm in cases of life- threatening arrhythmias such as ventricular fibrillation or pulseless VT. It is not used for stable VT because the patient still has a pulse and is not in immediate danger of cardiac arrest
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While this is a good safety measure for any client, it doesn't address the specific issue of homonymous hemianopsia.
B. This can be helpful for clients with motor difficulties but does not address the visual impairment.
C. Since the client has a right-sided stroke and homonymous hemianopsia, they will likely miss food on the left side of their tray. Reminding them to scan that area can help prevent them from missing food.
D. While this might seem logical, it doesn't address the underlying issue of the client's visual impairment.
Correct Answer is B
Explanation
A. In DIC, there is actually a consumption of clotting factors rather than an increase. The widespread activation of the clotting cascade leads to the consumption of clotting factors and platelets as they are used up in forming numerous small blood clots throughout the body. This depletion results in a paradoxical bleeding tendency due to a shortage of clotting factors.
B. This is characteristic of DIC. The condition involves both excessive clotting (thrombosis) and bleeding. The formation of small clots throughout the microcirculation leads to organ damage and depletion of clotting factors and platelets, which in turn causes bleeding tendencies. This dual process of clot formation and bleeding is a hallmark of DIC.
C. In DIC, there is a decrease in platelet count, not an increase. The condition causes widespread clotting, which consumes platelets rapidly, leading to a low platelet count. Therefore, a progressive increase in platelet count would not be expected in DIC.
D. Sodium and fluid retention are not primary features of DIC. Instead, DIC typically presents with symptoms related to clotting and bleeding rather than fluid balance. Fluid retention would be more associated with other conditions like heart failure or renal disorders, not directly with DIC.
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