A nurse is caring for a client who reports shortness of breath and heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse palpates a rapid carotid pulse with a blood pressure of 70/30, and the client reports feeling dizzy. The nurse should anticipate the need for which priority action?
Initiate external pacing.
Initiate CPR.
Defibrillation.
Synchronized cardioversion.
The Correct Answer is D
A. External pacing is not indicated for ventricular tachycardia with a pulse. Pacing is typically used for bradyarrhythmias.
B. CPR is only necessary if the client is pulseless. Since the client has a pulse, a more appropriate intervention is needed.
C. Defibrillation is used for pulseless VT or ventricular fibrillation, but this client has a pulse and is symptomatic.
D. Synchronized cardioversion is the appropriate intervention for unstable ventricular tachycardia with a pulse. The shock is synchronized to the R wave to prevent inducing ventricular fibrillation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pruritus is not a common side effect of heparin therapy. While allergic reactions can occur, they are not the primary concern.
B. Petechiae are a sign of bleeding, which is a major side effect of heparin therapy. Heparin increases the risk of bleeding by inhibiting clot formation, and petechiae may indicate early signs of hemorrhage.
C. Confusion is not directly associated with heparin therapy unless it results from severe bleeding leading to hypoxia or shock.
D. A slowing pulse rate is not a known adverse effect of heparin. Instead, monitoring for signs of bleeding, such as bruising, hematuria, and petechiae, is the priority.
Correct Answer is B
Explanation
A. Avoiding sick contacts is generally a good practice, but it is not the primary concern for a client with infective endocarditis. The focus is on preventing bacterial infections that could enter the bloodstream and affect the heart valves.
B. Prophylactic antibiotics are required before dental and invasive procedures to prevent bacterial endocarditis recurrence. The bacteria that cause infective endocarditis can enter the bloodstream through procedures that involve mucosal surfaces.
C. Discontinuing antibiotics when feeling better is incorrect. Infective endocarditis requires a full course of IV antibiotics, often lasting 4 to 6 weeks, to fully eradicate the infection and prevent complications.
D. Avoiding physical activity for six months is unnecessary unless the client has severe cardiac complications. However, clients should monitor for symptoms such as fatigue and consult their provider before engaging in strenuous activities.
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