Before giving any medication of cardiac dysrhythmia the LPN knows that the most important assessment that must be completed prior to giving the medication is:
Assessing the legs and feet for peripheral edema
Checking the results of the most recent ECG
Listening to the apical pulse for a full minute
Taking the blood pressure in both arms
The Correct Answer is C
A. Assessing the legs and feet for peripheral edema: While edema is an important indicator of heart failure, it does not provide real-time information about the electrical activity of the heart. Edema is a chronic sign of volume overload rather than an acute indicator of dysrhythmia severity. It is not the most critical assessment prior to antiarrhythmic administration.
B. Checking the results of the most recent ECG: An ECG provides a snapshot of previous electrical activity but may not reflect the patient's current hemodynamic status. The nurse must assess the patient's actual physiological presentation at the moment the medication is being given. Bedside assessment is superior to relying solely on historical diagnostic data.
C. Listening to the apical pulse for a full minute: Antiarrhythmic medications can significantly alter heart rate and rhythm, potentially causing profound bradycardia or new conduction blocks. Assessing the apical pulse for 60 seconds provides the most accurate baseline of the heart's current rate and regularity. This is a mandatory safety step to ensure the patient can tolerate the drug.
D. Taking the blood pressure in both arms: While blood pressure is a vital sign, it is a secondary manifestation of the heart's pumping efficiency rather than a direct measure of the rhythm. A single arm reading is usually sufficient unless a specific vascular discrepancy is suspected. The primary concern with dysrhythmia medications is the heart rate itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Maintain pressure over the insertion site: The femoral artery is a high-pressure vessel, and the puncture site is at significant risk for hematoma or hemorrhage. Applying a pressure dressing or sandbag helps ensure hemostasis during the initial recovery period. Monitoring the site for bleeding is a critical nursing priority to prevent hypovolemic complications.
B. Assist with amputation 2 hours after recovery: Amputation is not a standard or expected outcome of a cardiac catheterization procedure. This intervention would only be considered in the case of extreme, irreversible limb ischemia, which is a rare and severe complication. Nursing care focuses on preserving the limb through vigilant neurovascular assessment.
C. Place the client in semi-Fowler's position: Following a femoral artery catheterization, the patient must remain supine with the affected leg kept straight for several hours. Elevating the head of the bed to semi-Fowler's position increases intra-abdominal pressure and the risk of bleeding at the groin site. Hip flexion is strictly contraindicated until the artery has sufficiently healed.
D. Assess pedal pulses bilaterally: Frequent assessment of distal pulses is necessary to ensure that the catheterization did not cause an arterial occlusion or thrombosis. Comparing the pulses in both feet allows the nurse to detect subtle changes in perfusion to the affected extremity. Weak or absent pulses require immediate notification of the surgical team.
E. Monitor color and warmth of the left leg frequently: Skin temperature and color are essential indicators of arterial blood flow and tissue oxygenation. A cold, pale, or cyanotic limb suggests compromised circulation distal to the femoral insertion site. These neurovascular checks are vital for early detection of vascular complications following the invasive procedure.
Correct Answer is C
Explanation
A. "I will notify my doctor if my urine output increases after a few doses.": Diuresis is the intended pharmacological outcome for a patient with heart failure receiving loop diuretics. Increased urinary frequency and volume indicate that the medication is effectively reducing fluid overload. Reporting this expected finding would be an unnecessary use of clinical resources.
B. "I will not eat my usual banana with my breakfast cereal in the morning.": Furosemide promotes the excretion of potassium in the distal tubule and the loop of Henle. Bananas are a high-potassium food that helps prevent the development of hypokalemia during diuretic therapy. Restricting dietary potassium while taking a non-potassium-sparing diuretic increases the risk of cardiac arrhythmias.
C. "I will need to change positions slowly when going from laying down to sitting and then sitting to standing.": Rapid fluid volume reduction and vasodilation can lead to a significant drop in blood pressure upon standing. This orthostatic hypotension increases the risk of falls and syncope in older adult patients. Gradual transitions allow the body's baroreceptors to adjust and maintain adequate cerebral perfusion.
D. "I will take my furosemide with a full glass of water just before bed time.": Administering loop diuretics in the evening results in nocturia, which disrupts the patient's sleep cycle and increases fall risks at night. Medication should be taken in the morning to allow for peak diuresis during waking hours. Timing the dose correctly is essential for maintaining patient safety and quality of life.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.