An adult client is being admitted to the coronary care unit with a possible myocardial infarction (MI). The client reports feeling like they are going to "pass out." The cardiac monitor displays the rhythm shown. The client's respiratory rate is 12 to 16 breaths/minute and blood pressure is 78/52 mm Hg. The nurse auscultates clear breath sounds bilaterally and the skin is pale and diaphoretic. After administering oxygen, which action should the nurse prepare to perform?

Assist the client to perform vagal maneuver or bear down.

Give an anticholinergic medication.

Administer a sedative and cardiovert the client.

Give a beta blocker medication.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Assist the client to perform vagal maneuver or bear down: The ECG shows supraventricular tachycardia (SVT) with a very rapid, regular rhythm. While vagal maneuvers may help slow the rate in stable clients, this client’s hypotension (78/52 mm Hg) and presyncope indicate instability.

B. Give an anticholinergic medication: Anticholinergic agents like atropine are used for bradyarrhythmias, not for tachycardia. Administering such a drug would further increase the heart rate and worsen myocardial oxygen demand in this client with suspected myocardial infarction.

C. Administer a sedative and cardiovert the client: The rhythm and symptoms indicate unstable supraventricular tachycardia. Synchronized cardioversion is the immediate treatment for unstable tachyarrhythmias with a pulse to restore sinus rhythm and improve perfusion. Sedation is given beforehand if the client is conscious.

D. Give a beta blocker medication: Beta blockers are appropriate for stable tachyarrhythmias but can dangerously lower blood pressure in an unstable patient. The client’s hypotension and near-syncope require electrical rather than pharmacologic intervention.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Blood pressure measurement of 122/84 mm Hg and a heart rate of 88 beats/minute: These vital signs are within acceptable limits and do not indicate an acute complication following a cerebral angiogram. No immediate intervention is required for these values.

B. No urinary output measured since the procedure: While monitoring urine output is important, a two-hour gap post-procedure may not yet indicate a critical problem. The nurse should continue to monitor and assess, but this is not the most urgent finding.

C. Diminished volume of right dorsalis pedis pulse: A weak or absent peripheral pulse following femoral artery catheterization may indicate arterial obstruction, thrombus, or compromised distal perfusion. Immediate intervention is required to restore circulation and prevent tissue ischemia.

D. Client reports feeling hot during the procedure and cold afterward: These sensations may reflect normal physiological responses to contrast media or procedural stress. While worth noting, they do not require urgent intervention compared to compromised limb perfusion.

A. Transcutaneous pacing. B. Mechanical ventilation. C. Chest tube insertion. D. Synchronized cardioversion.

Correct Answer is A

Explanation

Rationale:
A. Transcutaneous pacing: The ECG rhythm demonstrates a third-degree (complete) heart block. This results in severe bradycardia and hypotension (80/50 mm Hg), placing the client at risk for syncope and cardiac arrest. Transcutaneous pacing is the immediate intervention to maintain cardiac output until a permanent pacemaker can be placed.

B. Mechanical ventilation: Although hypotension and bradycardia can lead to hypoxia, the client’s issue is primarily electrical conduction failure, not respiratory compromise. Ventilatory support would not correct the underlying cause of hemodynamic instability.

C. Chest tube insertion: Chest tube insertion is indicated for pneumothorax or hemothorax, not cardiac conduction abnormalities. There is no evidence of respiratory distress or pleural injury requiring this intervention.

D. Synchronized cardioversion: Cardioversion is used for tachydysrhythmias such as atrial fibrillation or supraventricular tachycardia. It is contraindicated in complete heart block, where electrical pacing not shock is required to restore effective cardiac rhythm and perfusion

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client returns to the unit following a cerebral angiogram via the femoral artery that was performed two hours ago. In assessing this client, which finding requires immediate intervention by the nurse?

Correct Answer is C

Explanation

A client admitted to the telemetry unit with a diagnosis of syncopal episodes has a sitting blood pressure of 80/50 mm Hg, a regular apical pulse, and a cardiac rhythm as shown on the monitor. The nurse should prepare the client for which procedure?

Correct Answer is A

Explanation

Patient Data Exhibits The healthcare provider (HCP) would like to do a thoracentesis on the client. The client's caregiver asks the nurse if there are any contraindications for the procedure. Performing a thoracentesis is contraindicated in which clinical manifestation (s)? Select all that apply.

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

A client's telemetry monitor indicates ventricular fibrillation (VF). Which should the nurse do first?

Based on this strip, which is the correct interpretation of this rhythm?

An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?