Review the EKG shown below, which displays rapid, erratic electrical impulses causing ineffective quivering instead of coordinated contraction.
What should be the nurse’s initial intervention?

Place the patient in a left lateral position and monitor vital signs.

Initiate cardiopulmonary resuscitation (CPR) immediately and prepare for defibrillation.

Administer Furosemide intravenously before considering other treatments.

Perform a thorough assessment to determine the cause of the arrhythmia before intervening.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Placing the patient in a left lateral position may not address the root cause of rapid, erratic electrical impulses. It stabilizes the airway but doesn't resolve the arrhythmia.

Choice B rationale

Initiating CPR and preparing for defibrillation are crucial. Rapid, erratic impulses suggest ventricular fibrillation, needing immediate CPR and defibrillation for survival.

Choice C rationale

Administering Furosemide, a diuretic, targets fluid overload but doesn't treat rapid, erratic electrical impulses like ventricular fibrillation, requiring immediate resuscitation.

Choice D rationale

A thorough assessment delays urgent intervention for life-threatening arrhythmias like ventricular fibrillation. Immediate CPR and defibrillation are essential for patient survival.

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Correct Answer is C

Explanation

Choice A rationale

Increased PAWP indicates left-sided heart failure, as it measures pressure in the left atrium and left ventricle. Right-sided heart failure typically presents with systemic venous congestion rather than pulmonary congestion. Normal PAWP: 6-12 mmHg.

Choice B rationale

Decreased specific gravity is not a typical finding in right-sided heart failure. Specific gravity measures urine concentration and can vary based on fluid intake and kidney function. Normal range: 1.005-1.030.

Choice C rationale

Ascending dependent edema results from increased venous pressure and fluid retention in the lower extremities, common in right-sided heart failure due to impaired venous return and fluid overload.

Choice D rationale

Decreased BNP is not characteristic of heart failure. BNP levels increase in response to ventricular volume expansion and pressure overload. Elevated BNP aids in diagnosing heart failure. Normal BNP: <100 pg/mL. .

A. Administer O2 to maintain oxygen saturation greater than 90%. B. Prepare the client for intubation. C. Apply continuous ECG monitoring. D. Obtain the client’s family history.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationales:

Administer O2 to maintain oxygen saturation greater than 90%: This prescription is indicated. Hypoxia can exacerbate cardiac and respiratory issues, so it is essential to maintain adequate oxygen levels in the blood. Supplemental oxygen can help improve tissue oxygenation and reduce strain on the heart.
Apply continuous ECG monitoring: This prescription is indicated. Continuous ECG monitoring is crucial in detecting arrhythmias and ischemic changes in a patient with cardiac symptoms and irregular pulse. Early detection allows for timely intervention and management of potentially life-threatening cardiac events.
Obtain the client’s family history: This prescription is nonessential. While obtaining a family history is useful for identifying potential genetic predispositions to cardiac and metabolic conditions, it is not immediately necessary for the acute management of the client’s current symptoms.
Prepare the client for intubation: This prescription is contraindicated. The client is currently maintaining an adequate respiratory rate and oxygen saturation on room air. There is no indication of respiratory failure or inability to maintain airway patency. Intubation would be an unnecessarily invasive procedure at this time.

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Review the EKG shown below, which displays rapid, erratic electrical impulses causing ineffective quivering instead of coordinated contraction.What should be the nurse’s initial intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure. Exhibits The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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Review the EKG shown below, which displays rapid, erratic electrical impulses causing ineffective quivering instead of coordinated contraction.
What should be the nurse’s initial intervention?