The nurse is caring for a client after a heart catheterization. What complication must the nurse intervene for immediately?
2+ bilateral peripheral edema
Heart rate 59 beats/min
Temperature of 96 F
Muffled heart sounds
The Correct Answer is D
A. Bilateral peripheral edema can occur after heart catheterization but is not as immediately life-threatening as cardiac tamponade.
B. A heart rate of 59 beats/min may be concerning, but bradycardia alone is not as immediately urgent as signs of cardiac tamponade.
C. A temperature of 96°F is low, but this is more of a concern for hypothermia or post-procedural effects and is not as urgent as muffled heart sounds indicating tamponade.
D. Muffled heart sounds can indicate cardiac tamponade, a medical emergency. Immediate intervention is required to relieve the pressure on the heart, which may involve pericardiocentesis to drain the fluid or blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
Calculation:
Desired dose: 0.25 mg
Available concentration: 0.1 mg/mL
Volume to administer: Desired dose / Available concentration = 0.25 mg / 0.1 mg/mL = 2.5 mL.
Correct Answer is D
Explanation
A. Amiodarone is an antiarrhythmic used to treat ventricular arrhythmias like monomorphic VT, but it is not the first-line treatment for a pulseless patient. Defibrillation should be performed immediately, and amiodarone can be administered after defibrillation if the rhythm persists.
B. CPR is essential for maintaining circulation in a pulseless patient, but defibrillation should be the first priority for monomorphic VT. CPR should be continued if defibrillation is not immediately available, but the most effective intervention is defibrillation to attempt to restore normal rhythm.
C. Cardioversion is used for stable, regular arrhythmias, but for a pulseless client in monomorphic VT, defibrillation is the appropriate first intervention. Cardioversion is typically used when the patient is conscious or stable and is not a priority for pulseless VT.
D. For a pulseless client with monomorphic ventricular tachycardia, defibrillation is the priority intervention. Defibrillation delivers an electric shock to the heart, which may terminate the abnormal rhythm and allow the heart to return to normal sinus rhythm. This is the most effective and immediate treatment for a pulseless client in ventricular tachycardia.
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