Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

Initiate cardiopulmonary resuscitation (CPR).

Establish intravenous (IV) access.

Carry out immediate defibrillation.

Check the client’s latest electrolyte levels.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Carry out immediate defibrillation.

Choice A rationale:

Initiating cardiopulmonary resuscitation (CPR) is essential for a client who is unresponsive and without a pulse. However, in the presence of ventricular fibrillation, immediate defibrillation is the priority to restore a viable heart rhythm.

Choice B rationale:

Establishing intravenous (IV) access is important for administering medications during resuscitation. However, it is not the immediate priority when defibrillation is indicated.

Choice C rationale:

Immediate defibrillation is the priority action for a client with ventricular fibrillation who is unresponsive and without a pulse. Defibrillation can quickly restore a normal heart rhythm, which is critical in saving the client’s life.

Choice D rationale:

Checking the client’s latest electrolyte levels can provide valuable information for ongoing treatment but is not the immediate priority in an emergency situation where defibrillation is indicated. Immediate action to restore the heart rhythm is more critical.

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Correct Answer is D

Explanation

Choice A rationale
High-output heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. High-output heart failure occurs when the heart is unable to meet the body’s increased demand for blood flow, which is not the case in this scenario.
Choice B rationale
Low-output heart failure is also not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Low-output heart failure occurs when the heart is unable to pump enough blood to meet the body’s needs, which is not the case in this scenario.
Choice C rationale
Left heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Left heart failure occurs when the left side of the heart is unable to pump enough blood to the body, which is not the case in this scenario.
Choice D rationale
Right heart failure is the correct answer. In the context of a 65-year-old male patient diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance, the nurse should assess for right heart failure. This is because the right side of the heart pumps blood to the lungs, and if the pulmonary vascular resistance is elevated, it can put strain on the right side of the heart, leading to right heart failure.

A. The patient should take the digoxin if their pulse is below 60 beats/min. B. The patient should notify the health care provider if they develop nausea. C. The patient should limit their dietary intake of potassium. D. The patient should take the hydrochlorothiazide at bedtime.

Correct Answer is B

Explanation

Choice A rationale
Digoxin slows the heart rate and increases the force of heart contractions, which can be beneficial in heart failure. However, if the pulse is below 60 beats/min, taking digoxin could further slow the heart rate and potentially lead to bradycardia.
Choice B rationale
Nausea can be a side effect of digoxin and hydrochlorothiazide. If the patient develops nausea, they should notify their healthcare provider as this could indicate that the medication dose needs adjustment.
Choice C rationale
Hydrochlorothiazide can cause the body to lose potassium, so limiting dietary intake of potassium could potentially lead to hypokalemia, a condition characterized by low potassium levels in the blood.
Choice D rationale
Taking hydrochlorothiazide at bedtime could potentially lead to nocturia, which is the need to wake up at night to urinate. This could disrupt the patient’s sleep.

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Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of a 65-year-old male patient diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance, which type of heart failure should the nurse assess for in this patient?

Correct Answer is D

Explanation

In the context of Interprofessional Care of the Client and Family Across the Lifespan, a nurse is planning discharge teaching for a patient with chronic heart failure who has been prescribed digoxin (Lanoxin) and hydrochlorothiazide. What instruction should the nurse include in the teaching?

Correct Answer is B

Explanation

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