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 D
Explanation
Choice A rationale
Troponin is a specific biomarker released during myocardial cell necrosis, typically peaking between 12 to 24 hours after injury. The normal range for Troponin T is less than 0.01 ng/mL. While essential for diagnosing an infarction, it is a laboratory value that requires time for processing. It does not provide the immediate diagnostic visualization needed to distinguish between ST-elevation myocardial infarction and non-ischemic causes of chest pain in the first minutes of care.
Choice B rationale
Aspirin acts as an antiplatelet agent by irreversibly inhibiting cyclooxygenase-1, which prevents the synthesis of thromboxane A2. This action inhibits platelet aggregation and reduces the risk of further thrombus formation in the coronary arteries. While administration is a high priority in the acute coronary syndrome protocol, the nurse must first establish the underlying cardiac rhythm and electrical status via an electrocardiogram to guide the overall speed and type of medical intervention required.
Choice C rationale
Monitoring intake and output is a standard nursing intervention used to evaluate fluid balance and renal perfusion, which can be compromised in heart failure or cardiogenic shock. However, in the hyperacute phase of chest pain, this task is not a life-saving or diagnostic priority. Measuring urine output or fluid intake does not address the immediate need to identify coronary ischemia or prevent further myocardial damage during the initial emergency department assessment.
Choice D rationale
A 12-lead ECG is the gold standard for immediate assessment of chest pain because it identifies myocardial ischemia or injury within seconds. It allows the clinical team to recognize ST-segment elevation, which necessitates rapid reperfusion therapy like fibrinolysis or percutaneous coronary intervention. According to standard emergency protocols, an ECG should be performed and interpreted within 10 minutes of arrival to minimize the door-to-balloon time and preserve viable myocardial tissue from irreversible necrosis.
Correct Answer is A
Explanation
Choice A rationale
Cardiac catheterization is the gold standard for visualizing the coronary anatomy through fluoroscopy and radiopaque contrast injection. It allows the physician to identify the exact location and severity of atherosclerotic plaques or occlusions. By determining the percentage of narrowing in the vessels, the medical team can decide if the patient requires medical management, stenting, or surgical bypass. This direct visualization provides definitive information regarding the blood supply to the various regions of the heart muscle.
Choice B rationale
While cardiac catheterization can involve a ventriculogram to estimate the ejection fraction and assess wall motion, this is usually a secondary objective. Non-invasive tests like an echocardiogram are typically the first-line tools used to evaluate how efficiently the heart muscle contracts. The primary and most common reason for invasive catheterization remains the assessment of the coronary arteries rather than just muscular function. Ejection fraction reflects the percentage of blood pumped out of the left ventricle.
Choice C rationale
Evaluating the electrical activity of the heart is primarily the role of an electrocardiogram or an electrophysiology study. While catheters are used in electrophysiology studies to map conduction pathways, a standard cardiac catheterization focused on the coronary arteries does not primarily aim to assess arrhythmias. Identifying the heart's electrical rhythm involves measuring millivolts of electrical potential across the cardiac membranes. This is distinct from the hemodynamic and anatomical data collected during a routine coronary angiogram.
Choice D rationale
Cardiovascular response to stress is usually evaluated through non-invasive stress testing, such as a treadmill test or a pharmacological stress test combined with imaging. These tests observe the heart's behavior under increased metabolic demand to detect signs of inducible ischemia. Cardiac catheterization is an invasive procedure typically performed after a stress test has yielded abnormal results or when a patient presents with acute symptoms. It provides a static view of the anatomy rather than a functional stress assessment.
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