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 A
Explanation
Provide a quiet, low-stimulus environment
Choice A Reason:
Provide a quiet, low-stimulus environment
This is the correct answer. A quiet, low-stimulus environment helps to reduce the metabolic demands on the body and prevent overstimulation, which can trigger a thyroid crisis. Hyperthyroidism increases the body’s metabolic rate, and excessive stimulation can exacerbate symptoms and lead to a crisis. Therefore, creating a calm environment is crucial in managing hyperthyroidism and preventing complications.
Choice B Reason:
Keep the client NPO
Keeping the client NPO (nothing by mouth) is not typically necessary for preventing a thyroid crisis. While it may be required for certain procedures or if the client is experiencing severe symptoms, it is not a standard intervention for hyperthyroidism management. Therefore, this choice is not correct.
Choice C Reason:
Administer aspirin as prescribed for any sign of hyperthermia
Administering aspirin for hyperthermia is not recommended in clients with hyperthyroidism. Aspirin can increase free thyroid hormone levels by displacing thyroid hormones from their binding proteins, potentially worsening hyperthyroidism. Instead, other antipyretics like acetaminophen are preferred. Therefore, this choice is not correct.
Choice D Reason:
Observe the client carefully for signs of hypocalcemia
Observing for signs of hypocalcemia is not directly related to preventing a thyroid crisis. Hypocalcemia is more commonly associated with thyroidectomy or parathyroidectomy rather than hyperthyroidism itself. Therefore, this choice is not correct.
Correct Answer is ["B"]
Explanation
Choice A Reason:
I sleep at least 8 hours each night.
This statement is not concerning because getting adequate sleep is generally a sign of good health. It does not directly relate to symptoms of high blood glucose levels. Therefore, this choice is not relevant to the nurse’s concerns regarding the client’s elevated blood glucose level.
Choice B Reason:
I cannot seem to quench my thirst.
This statement is concerning because excessive thirst, known as polydipsia, is a common symptom of high blood glucose levels or hyperglycemia. When blood glucose levels are elevated, the body tries to eliminate the excess glucose through urine, leading to dehydration and increased thirst. This symptom indicates that the client’s blood glucose levels may be poorly controlled, which requires medical attention.
Choice C Reason:
I have to void nearly every hour.
Frequent urination, or polyuria, is another symptom of high blood glucose levels. When there is too much glucose in the blood, the kidneys work harder to filter and absorb it. When they can’t keep up, the excess glucose is excreted into the urine, pulling fluids from the tissues and causing frequent urination. This symptom is a clear indicator of hyperglycemia and needs to be addressed by the nurse.
Choice D Reason:
At times my vision is blurry.
Blurred vision can be a symptom of high blood glucose levels. Elevated glucose levels can cause the lens of the eye to swell, leading to changes in vision. This symptom is concerning because it suggests that the client’s blood glucose levels are affecting their vision, which can be a sign of poorly managed diabetes or other complications.
Choice E Reason:
I have lost 10 pounds without even trying.
Unintentional weight loss is a concerning symptom of high blood glucose levels. When the body cannot use glucose for energy due to insulin resistance or lack of insulin, it starts to break down muscle and fat for energy, leading to weight loss. This symptom indicates that the client’s diabetes may be uncontrolled, and immediate medical intervention is necessary.
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