A patient with a cardiac disorder is having increased premature ventricular contractions and feels "anxious" and short of breath. After vital signs are obtained, what actions should the nurse take? Select all that apply.
Notify the health-care provider.
Start oxygen at 2 L/min.
Order an electrocardiogram and cardiac enzymes.
Place bed in modified Trendelenburg position.
Allow the patient to rest alone.
Elevate the head of the bed.
Correct Answer : A,B,C,F
A. Increased premature ventricular contractions along with symptoms of anxiety and shortness of breath may indicate worsening cardiac function or an acute cardiac event, necessitating immediate medical attention.
B. Oxygen therapy may help alleviate symptoms of shortness of breath and improve oxygenation in patients experiencing cardiac symptoms.
C. These diagnostic tests can provide valuable information about cardiac function and any potential myocardial damage or ischemia, helping guide further treatment and management.
D. The modified Trendelenburg position may increase cardiac workload, which is not beneficial in the case of PVCs.
E. The patient should not be left alone due to the need for ongoing assessment and potential rapid intervention. Furthermore, leaving them alone could worsen their anxiety.
F. Elevating the head of the bed can aid in breathing and comfort, reducing the sensation of breathlessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While atrial fibrillation with a rapid ventricular response requires attention, it is not an immediate concern unless associated with symptoms such as chest pain, shortness of breath, or hemodynamic instability.
B. A heart rate of 50 in a patient with a newly inserted permanent pacemaker may indicate bradycardia, which could be a sign of pacemaker malfunction or lead dislodgement. This patient requires immediate assessment to rule out complications.
C. While recent implantable cardioverter-defibrillator (ICD) discharge warrants evaluation, the patient is currently in normal sinus rhythm with a heart rate of 68, suggesting stability. This patient's assessment can be prioritized after the patient with the pacemaker issue is seen.
D. A heart rate of 58 in a patient with chronic atrial fibrillation on beta-blocker therapy may not be immediately concerning if the patient is asymptomatic and hemodynamically stable. This patient can be assessed after addressing the more urgent pacemaker issue.
Correct Answer is ["A","B","C","D","E"]
Explanation
First, Hodgkin lymphoma (HL) is commonly characterized by painless lymphadenopathy and is not painful, as stated above. Secondly, HL is often characterized by a low-grade fever rather than a high fever. Third, the presence of Bence-Jones cells in a laboratory test is not associated with Hodgkin lymphoma but indicates multiple myeloma, a different type of cancer. Fourth, Hodgkin disease is indeed a form of cancer; it is a malignancy of the lymphatic system. The nurse's statement that it is "not really cancer" is incorrect and misleading. Fifth, palliative radiation therapy is typically used to relieve symptoms in advanced stages of cancer or non-curative scenarios. However, for stage 1 Hodgkin lymphoma, the treatment usually involves chemotherapy and/or radiation therapy with curative intent, not palliative. Joe's nurse should provide accurate information about the nature of Hodgkin's disease and its treatment options, which are based on the stage and specific characteristics of the lymphoma.
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