The client is found in ventricular fibrillation. What interventions should the team implement? Select All That Apply

Bring the crash cart to the bedside

Start Cardiopulmonary resuscitation.

Defibrillate the client

Administer Adenosine (Adenocard) to assist in determining the patient's rhythm

Consider the "Hs and Ts" (reversible causes of cardiac arrest) to determine appropriate treatment.

Answer and Explanation

Correct Answer : A,B,C,E

A. Bring the crash cart to the bedside: Essential for advanced cardiac life support (ACLS), including defibrillation and medications.

B. Start cardiopulmonary resuscitation: High-quality CPR is critical to maintain circulation until defibrillation can occur.

C. Defibrillate the client: Defibrillation is the definitive treatment for ventricular fibrillation to restore a normal rhythm.

D. Administer adenosine (Adenocard) to assist in determining the rhythm: Adenosine is used for diagnosing or treating certain supraventricular tachycardias, not ventricular fibrillation.

E. Consider the "Hs and Ts": Identifying reversible causes of cardiac arrest (e.g., hypoxia, hypothermia, toxins) is part of the ACLS protocol.

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Correct Answer is D

Explanation

A. Removing the cast correctly at the end of the treatment period. The nurse would not instruct the patient to remove the cast. This should be done by a healthcare provider at the appropriate time.

B. Using crutches efficiently. While crutch use is important, it is secondary to monitoring for impaired circulation, which can have immediate, serious consequences.

C. Exercising joints above and below the cast, as prescribed. This may be part of rehabilitation but does not have the same urgency as monitoring circulation for complications.

D. Reporting signs of impaired circulation. The nurse should emphasize the importance of monitoring for signs of impaired circulation, such as increased pain, numbness, or color changes, which could indicate complications like compartment syndrome or poor blood flow.

A. Auscultate for a pericardial friction rub B. Inspect the skin for petechia C. Palpate the radial pulses bilaterally D. Assess for abdominal pain

Correct Answer is A

Explanation

A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.

B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.

C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.

D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.

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The client is found in ventricular fibrillation. What interventions should the team implement? Select All That Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge education to a client who is going home with a cast on his leg. What education should the nurse emphasize in the teaching session?

Correct Answer is D

Explanation

A patient recovering from a myocardial infarction (MI) develops cheat pain on day 3 that increases when taking a deep breath, lying flat, and is relieved by leaning forward. Which additional assessment data should the nurse collect next?

Correct Answer is A

Explanation

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