The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

A patient with second-degree atrioventricular (AV) block, type 1. rate 60, who is dizzy when ambulating

A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago

A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due

A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due.

Answer and Explanation

The Correct Answer is D

A. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating. While dizziness may be a concern, second-degree AV block type 1 (Wenckebach) typically resolves without immediate intervention.

B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago. This patient is stable, and recovery from cardioversion typically involves monitoring, but the patient does not require immediate intervention.

C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due. The patient is stable, and the dose of warfarin can be administered after assessing the patient’s overall condition, making it a lower priority.

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due: The patient whose ICD fired twice is at high risk for life-threatening arrhythmias, and this situation requires immediate evaluation and intervention. The nurse should assess the patient first, and the dose of amiodarone may be administered to manage any underlying arrhythmias.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Apply warm compresses to site of the client's pacemaker insertion: Heat application is contraindicated as it may increase swelling or risk infection.

B. Teach the client to avoid being near any type of household microwave oven: Modern pacemakers are shielded, so microwaves do not interfere with their function.

C. Ambulate the client as soon as possible to evaluate pacemaker function: While early ambulation is encouraged, pacemaker function is not evaluated through ambulation.

D. Instruct client to limit movement of the arm on side where pacemaker was inserted: Limiting arm movement prevents dislodging the pacemaker leads during the healing phase.

A. Hold the medication and notify the HCP B. Administer the medication as ordered. C. Prepare to administer vitamin K (AquaMephyton). D. Assess the client for abnormal bleeding. E. Fat embolism

Correct Answer is B

Explanation

A. Hold the medication and notify the HCP: This is unnecessary. An INR of 2.7 is within the therapeutic range for a client with a mechanical valve replacement (2.5 to 3.5). No intervention is required.

B. Administer the medication as ordered: The INR of 2.7 is within the desired therapeutic range for clients on warfarin with mechanical valve replacements, so the nurse should proceed with the prescribed dose.

C. Prepare to administer vitamin K (AquaMephyton): Vitamin K is used to reverse the effects of warfarin if the INR is too high (usually greater than 5).

D. Assess the client for abnormal bleeding: While important, this is not the first action. The INR is within the therapeutic range, so the priority is to administer the medication.

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The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has just had a pacemaker inserted. Which action should the nurse include in the initial plan of care?

Correct Answer is D

Explanation

A nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?

Correct Answer is B

Explanation

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