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 D

Explanation

Choice A rationale

Flushed, warm legs are characteristic of chronic venous insufficiency, not peripheral artery disease, which results in poor arterial blood flow and cool extremities.

Choice B rationale

Thin, pliable toenails suggest nutritional deficiencies or fungal infections, not advanced peripheral artery disease, which often leads to thick, brittle nails.

Choice C rationale

Hairy legs are indicative of adequate blood flow. In peripheral artery disease, decreased blood flow results in hair loss on the legs.

Choice D rationale

Leg pain at rest, called rest pain, signifies advanced peripheral artery disease due to severe arterial insufficiency and poor oxygen supply to tissues. .

NGN QUESTIONS

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 is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

Correct Answer is D

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?