The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.)
Provide continued sedation.
Remove crash cart from the room.
Assess the chest for burns.
Ensure electrodes are in place for continued monitoring.
Document results of the procedure.
Correct Answer : C,D,E
Choice A Reason:
Provide continued sedation.
Providing continued sedation is not typically necessary after a cardioversion. The sedation used during the procedure is usually short-acting, and the client should begin to wake up shortly after the procedure is completed. Continuous sedation is not required unless there are specific medical reasons, which should be determined by the healthcare provider.
Choice B Reason:
Remove crash cart from the room.
The crash cart should remain in the room until the client is fully stable. Removing it immediately after the procedure is not advisable because the client may still be at risk for complications such as arrhythmias or other cardiac events. Keeping the crash cart nearby ensures that emergency equipment is readily available if needed.
Choice C Reason:
Assess the chest for burns.
Assessing the chest for burns is an important nursing action following a cardioversion. The electrical shock delivered during the procedure can cause burns on the skin where the electrodes were placed. It is essential to check for any signs of burns or skin irritation and provide appropriate care if needed.
Choice D Reason:
Ensure electrodes are in place for continued monitoring.
Ensuring that the electrodes are in place for continued monitoring is crucial. Continuous cardiac monitoring is necessary to observe the client’s heart rhythm and detect any potential complications or recurrence of arrhythmias. Proper placement and function of the electrodes are essential for accurate monitoring.
Choice E Reason:
Document results of the procedure.
Documenting the results of the procedure is a critical nursing action. Accurate documentation includes noting the client’s response to the cardioversion, any complications, and the current heart rhythm. This information is vital for ongoing care and communication with the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A: Lean on your back with your knees bent.
Reason: This instruction is incorrect. Pursed lip breathing is typically performed in a seated position with the neck and shoulders relaxed. Lying on your back with knees bent is not a recommended position for this breathing technique.
Choice B: Use your abdominal muscles to squeeze air out of your lungs.
Reason: This instruction is correct. Using the abdominal muscles helps to expel air more effectively from the lungs, which is a key component of pursed lip breathing. This technique helps to improve ventilation and reduce the work of breathing.
Choice C: Breathe out slowly without puffing your cheeks.
Reason: This instruction is correct. Breathing out slowly through pursed lips without puffing the cheeks helps to keep the airways open longer, allowing more air to be expelled from the lungs. This technique is particularly beneficial for individuals with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice D: Focus on inhaling and holding your breath as long as you can.
Reason: This instruction is incorrect. The focus of pursed lip breathing is on controlled exhalation rather than holding the breath. Inhaling should be done slowly through the nose, and exhaling should be prolonged through pursed lips.
Choice E: Exhale at least twice the amount of time it took to breathe in.
Reason: This instruction is correct. The exhalation phase should be longer than the inhalation phase, typically taking at least twice as long. This helps to improve the efficiency of breathing and reduce shortness of breath.
Choice F: Open your mouth and breathe deeply.
Reason: This instruction is incorrect. Pursed lip breathing involves breathing in through the nose and exhaling through pursed lips. Opening the mouth and breathing deeply is not part of this technique.
Correct Answer is ["B","C"]
Explanation
Choice A Reason: High-flow nasal cannula
The high-flow nasal cannula (HFNC) is designed to deliver oxygen at flow rates much higher than 5 liters per minute, typically ranging from 20 to 60 liters per minute. It is used for patients requiring high levels of oxygen and positive airway pressure. Therefore, it is not appropriate for a flow rate of 5 liters per minute.
Choice B Reason: Simple face mask
The simple face mask is suitable for delivering oxygen at flow rates between 6 to 10 liters per minute. However, it can also be used at a flow rate of 5 liters per minute, providing an FiO2 (fraction of inspired oxygen) of approximately 40-60%. This makes it an appropriate choice for the given requirement.
Choice C Reason: Nasal cannula
The nasal cannula is a low-flow oxygen delivery device that can deliver oxygen at flow rates from 1 to 6 liters per minute. At 5 liters per minute, it provides an FiO2 of approximately 40%. It is comfortable for patients and is commonly used for those who need a moderate amount of supplemental oxygen.
Choice D Reason: Non-rebreather mask
The non-rebreather mask is designed to deliver high concentrations of oxygen, typically at flow rates of 10 to 15 liters per minute. It is used in situations where patients need a high FiO2, close to 100%. Therefore, it is not suitable for a flow rate of 5 liters per minute.
Choice E Reason: Venturi mask
The Venturi mask is used to deliver precise oxygen concentrations, typically ranging from 24% to 60% FiO2. It is suitable for patients who require controlled oxygen therapy. While it can be adjusted to deliver oxygen at a flow rate of 5 liters per minute, it is generally used for more specific FiO2 requirements.
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