The client's 12-lead electrocardiogram (ECG) waveform indicates the rhythm has changed from 1st degree to 3rd degree atrioventricular (AV) heart block. Which intervention should the nurse implement?
Assess the client's blood pressure.
Administer propranolol via IV push (IVP).
Document the increase in the client's heart rate.
Initiate cardiopulmonary resuscitation (CPR).
The Correct Answer is A
Rationale:
A. Assess the client's blood pressure: Progression to third-degree AV block can significantly impair cardiac output due to loss of atrioventricular synchrony. Assessing blood pressure helps determine hemodynamic stability and guides urgency of further interventions such as pacing.
B. Administer propranolol via IV push (IVP): Propranolol is a beta-blocker that further slows AV nodal conduction and can worsen complete heart block. Its administration may precipitate severe bradycardia, hypotension, or cardiac arrest. AV nodal–blocking agents are contraindicated in third-degree AV block.
C. Document the increase in the client's heart rate: Third-degree AV block is characterized by atrial and ventricular dissociation, often with a slow ventricular escape rhythm. An increase in heart rate is not expected and is not the priority focus. Immediate assessment of perfusion takes precedence over documentation.
D. Initiate cardiopulmonary resuscitation (CPR): CPR is indicated only if the client is pulseless or in cardiac arrest. Clients with third-degree AV block may still have a perfusing rhythm. Assessment and preparation for advanced interventions are required before initiating resuscitation measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A Yankauer suction: This rigid suction device is used for clearing oral secretions in clients who are spontaneously breathing. While useful, it does not provide immediate ventilatory support for a mechanically ventilated or suddenly apneic client.
B. A bag valve mask (BVM): A BVM is essential at the bedside for any intubated or ventilated client. It allows the nurse to manually ventilate the client in case of ventilator failure, accidental extubation, or acute respiratory compromise, ensuring rapid oxygenation and ventilation.
C. The crash cart: A crash cart contains emergency medications and defibrillation equipment. While important for code situations, it is not specific to immediate ventilatory support at the bedside and may be located nearby rather than directly at the client’s side.
D. A tracheostomy set: A tracheostomy set is required for clients with established tracheostomies or anticipated need for surgical airway access. For a postoperative client with an endotracheal tube, immediate ventilatory support is more effectively provided by a BVM, making it the priority equipment.
Correct Answer is A
Explanation
Rationale:
A. No spontaneous respirations over set rate: Absence of spontaneous respirations in a mechanically ventilated client indicates inadequate ventilation or possible ventilator malfunction. Immediate intervention is required to prevent hypoxia and respiratory arrest.
B. Abdominal girth increase of 2 inches (5.1 cm): While this may indicate internal bleeding or fluid accumulation after AAA repair, it is not immediately life-threatening compared to absent respirations. It requires urgent monitoring and notification but does not take precedence over airway and ventilation.
C. Urine output less than fluid intake: Reduced urine output may suggest hypoperfusion or early renal compromise. This requires ongoing monitoring and intervention but is not as acutely critical as inadequate ventilation.
D. Core body temperature of 101° F (38.3° C): Mild fever may occur postoperatively and should be monitored for infection. While important, it does not require the immediate action that absent respirations demand.
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