A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?

Start CPR

Prepare for radiofrequency catheter ablation

Prepare for defibrillation

Prepare for cardioversion

Answer and Explanation

The Correct Answer is D

A. Start CPR: CPR is indicated if the client is unresponsive and pulseless, which is not the case here as the client is alert.

B. Prepare for radiofrequency catheter ablation: This is a long-term treatment for recurrent VT but not appropriate for acute management.

C. Prepare for defibrillation: Defibrillation is used for pulseless VT or ventricular fibrillation, not for a stable VT with a pulse.

D. Prepare for cardioversion: Synchronized cardioversion is the appropriate intervention for a stable VT with a pulse to restore normal rhythm.

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Correct Answer is C

Explanation

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.

B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.

C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.

D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.

A. Hold the medication and notify the HCP B. Administer the medication as ordered. C. Prepare to administer vitamin K (AquaMephyton). D. Assess the client for abnormal bleeding. E. Fat embolism

Correct Answer is B

Explanation

A. Hold the medication and notify the HCP: This is unnecessary. An INR of 2.7 is within the therapeutic range for a client with a mechanical valve replacement (2.5 to 3.5). No intervention is required.

B. Administer the medication as ordered: The INR of 2.7 is within the desired therapeutic range for clients on warfarin with mechanical valve replacements, so the nurse should proceed with the prescribed dose.

C. Prepare to administer vitamin K (AquaMephyton): Vitamin K is used to reverse the effects of warfarin if the INR is too high (usually greater than 5).

D. Assess the client for abnormal bleeding: While important, this is not the first action. The INR is within the therapeutic range, so the priority is to administer the medication.

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A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse observes a new graduate nurse who is caring for a client who has a severe head injury. Which action by the new graduate nurse requires the charge nurse to intervene?

Correct Answer is C

Explanation

A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

Correct Answer is B

Explanation

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