An older adult male client is admitted after three reported syncopal episodes at home. He has several bruises at various stages of healing noted over his arms and legs. The cardiac monitor shows atrial fibrillation (A-fib) with a ventricular response of 140 beats/minute. In addition to contacting the client's healthcare provider (HCP), which intervention should the nurse implement?
Contact the client's healthcare power of attorney.
Call for immediate help from the rapid response team (RRT).
Report the client's falls and bruises to adult protective services.
Monitor the client's blood pressure and oxygen saturation.
The Correct Answer is D
A. Contact the client's healthcare power of attorney: This is appropriate if the client is unable to make decisions or if end-of-life care planning is being addressed. However, the client is alert enough to report syncopal episodes, and the priority is stabilizing his condition.
B. Call for immediate help from the rapid response team (RRT): The rapid response team is called for acute, life-threatening changes in clinical. Although the client is tachycardic, there is no indication of immediate decompensation requiring emergency intervention.
C. Report the client’s falls and bruises to adult protective services: The presence of bruises alone is not sufficient to trigger a report without further assessment. These bruises may be related to the syncopal events. The nurse must first assess and stabilize the client.
D. Monitor the client’s blood pressure and oxygen saturation: With atrial fibrillation and a rapid ventricular response, the client is at risk for hemodynamic instability. Monitoring vital signs helps determine whether the high heart rate is compromising perfusion or oxygenation, guiding the urgency of treatment and further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Low-density lipoproteins (LDL) 185 mg/dL (4.79 mmol/L): This LDL value is significantly above the recommended level for a client with a history of myocardial infarction. Elevated LDL contributes to atherosclerotic plaque formation and increases the risk of further cardiac events.
B. Triglycerides 155 mg/dL (1.75 mmol/L): Although this value is at the higher end of the normal range, it is still within acceptable limits. While elevated triglycerides are a cardiovascular risk factor, this level alone does not require urgent follow-up.
C. Lipase 50 units/L (0.83 μkat/L): This lipase level is well within the normal range and is not relevant to cardiac health. Lipase is typically used to evaluate pancreatic function and has no direct bearing on post-myocardial infarction follow-up.
D. High-density lipoproteins (HDL) 60 mg/dL (1.55 mmol/L): This HDL value is above the recommended minimum and is actually considered protective against heart disease. No follow-up is needed for this value, as it reflects favorable cardiovascular risk status.
Correct Answer is A
Explanation
A. Rhythm of apical heart rate: Assessing the rhythm of the apical heart rate is most important, especially with a rate of 168 bpm. This could indicate a tachydysrhythmia (e.g., atrial fibrillation with rapid ventricular response or supraventricular tachycardia) contributing to the new shortness of breath.
B. Volume of pedal pulses: Although assessing peripheral perfusion is important, pedal pulses are not the priority in the context of a dangerously high heart rate and new respiratory symptoms.
C. Degree of skin elasticity: Skin turgor evaluates hydration but is not directly relevant in the setting of acute cardiac symptoms. It does not provide timely data to explain the new-onset shortness of breath or tachycardia.
D. Length of capillary refill: Capillary refill is a general indicator of perfusion, but it is less specific and immediate compared to assessing the heart rhythm. It may be slightly delayed in this case but won’t clarify the underlying cardiac issue.
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