The nurse is assigned to care for several clients admitted to a telemetry unit.
Which client should the nurse assess first?
A client whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift, requiring amiodarone IV.
A client diagnosed with new onset of atrial fibrillation, requiring scheduled IV diltiazem.
A client returned from an electrophysiology procedure 2 hours ago, reporting constipation.
A client who received elective cardioversion 1 hour ago and whose heart rate (HR) is 115 bpm.
The Correct Answer is A
Choice A rationale
This client is the highest priority due to significant cardiovascular instability evidenced by the implantable cardioverter defibrillator firing twice. This indicates the client experienced life-threatening ventricular arrhythmias, such as ventricular tachycardia or fibrillation, within the last shift. The administration of amiodarone, a Class III antiarrhythmic, further highlights the severity of the irritability in the ventricular myocardium. The nurse must assess for continued arrhythmias, electrolyte imbalances like potassium 3.5 to 5.0 mEq/L, and signs of decreased cardiac output.
Choice B rationale
New onset atrial fibrillation requires medical management to control the ventricular rate and prevent thromboembolism, but it is generally less immediately life-threatening than recurring ventricular arrhythmias. Scheduled IV diltiazem is a calcium channel blocker used for rate control. While the client needs assessment for hemodynamic stability and a heart rate usually kept below 100 beats per minute, they do not take precedence over a client whose heart recently required internal shocks to maintain a rhythm.
Choice C rationale
A client who is 2 hours post-electrophysiology procedure reporting constipation is the lowest priority. While post-procedure assessments are important to check the insertion site for hematoma or hemorrhage and peripheral pulses, a complaint of constipation is a non-urgent gastrointestinal issue. It does not indicate a compromise in the ABCs (Airway, Breathing, Circulation) or a complication of the cardiac procedure itself. This can be addressed after the unstable cardiac clients have been thoroughly assessed and stabilized.
Choice D rationale
Elective cardioversion is a controlled procedure used to restore a normal sinus rhythm. A heart rate of 115 beats per minute 1 hour post-procedure indicates tachycardia, which may mean the procedure was unsuccessful or that the client is experiencing anxiety or pain. While this requires follow-up assessment and potentially further intervention, the client is currently more stable than the client in Choice A, whose device had to fire autonomously to prevent sudden cardiac death from a ventricular rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hyperglycemia is not a typical complication of combining ACE inhibitors and diuretics, although some diuretics like thiazides can slightly affect glucose levels. Hypokalemia is a common side effect of loop or thiazide diuretics, but ACE inhibitors actually promote potassium retention. Therefore, the risk of hypokalemia is often mitigated when these two drugs are used together. This choice does not represent the most significant or common combined risk associated with this specific drug pairing in heart failure.
Choice B rationale
ACE inhibitors and diuretics both lower blood pressure, which can lead to profound hypotension, especially during the initiation of therapy. Additionally, ACE inhibitors block the secretion of aldosterone, which normally promotes potassium excretion; this results in a risk of hyperkalemia. While some diuretics waste potassium, the potassium-retaining effect of the ACE inhibitor is a critical monitoring point. The combination of reduced vascular resistance and decreased fluid volume makes hypotension a primary concern for patient safety.
Choice C rationale
Hypertension is unlikely when a patient is taking two different types of antihypertensive medications. Both ACE inhibitors and diuretics are intended to lower blood pressure by reducing systemic vascular resistance and blood volume, respectively. Furthermore, while diuretics can cause hypokalemia, the presence of an ACE inhibitor makes hyperkalemia a more significant concern due to its effect on the renin-angiotensin-aldosterone system. This option incorrectly identifies both the blood pressure trend and the electrolyte risk.
Choice D rationale
Hypoglycemia is not a recognized side effect of ACE inhibitors or diuretics. Hyponatremia can occur with diuretic use due to the inhibition of sodium reabsorption in the renal tubules, but it is not the most common or characteristic complication when paired specifically with an ACE inhibitor. The most significant and immediate risks involve the regulation of potassium and the maintenance of adequate systemic perfusion pressure, making the monitoring of blood pressure and potassium levels the nursing priority.
Correct Answer is C
Explanation
Choice A rationale
Sinus bradycardia involves a heart rate below 60 beats per minute, which is typically contrary to the presentation of atrial fibrillation. In atrial fibrillation, the multiple rapid impulses from the atria usually lead to a rapid ventricular response, causing tachycardia rather than bradycardia. While medications like beta blockers or calcium channel blockers can cause slow rates, the primary pathological complication of the arrhythmia itself is not bradycardia but rather hemodynamic instability or thromboembolic events.
Choice B rationale
Peripheral vascular disease is a chronic condition characterized by the narrowing of arteries outside the heart and brain, often due to atherosclerosis. While both atrial fibrillation and peripheral vascular disease share common risk factors like hypertension or age, atrial fibrillation does not directly cause peripheral vascular disease. The concern in atrial fibrillation is the formation of acute arterial emboli that can travel to the limbs, causing acute ischemia, which is distinct from the chronic progression of systemic atherosclerosis.
Choice C rationale
Atrial fibrillation causes ineffective atrial contraction, leading to blood stasis within the atria, especially the left atrial appendage. This stasis facilitates the formation of thrombi. If a clot forms in the right atrium and dislodges, it travels through the right ventricle into the pulmonary circulation, resulting in a pulmonary embolism. Conversely, left-sided clots lead to systemic strokes. Monitoring for sudden shortness of breath or chest pain is essential due to this high thromboembolic risk.
Choice D rationale
Hypertension is frequently a precursor or a comorbid condition that contributes to the development of atrial fibrillation by causing structural remodeling of the heart. However, atrial fibrillation itself does not cause hypertension. In many cases, the loss of atrial kick and rapid heart rate associated with atrial fibrillation can actually lead to a decrease in cardiac output, which might manifest as hypotension or a drop in blood pressure rather than an elevation in pressure.
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