The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but complains of slight nausea after eating breakfast. What is the nurse's best action?

Perform a 12 lead EKG and request an order for bumetanide 0.5 mg IV

Administer pantoprazole sodium 40 mg by mouth to decrease GI distress

Administer carvedilol 10 mg by mouth and reassess in 30 minutes

Complete the remainder of the assessment and continue to monitor

Answer and Explanation

The Correct Answer is D

A.   The 12-lead EKG might be unnecessary right now, especially since the client has no other alarming symptoms. Bumetanide is also not indicated for nausea or tachycardia in this scenario.
B.   There is no clear indication that the nausea is related to acid reflux or GI distress that would justify pantoprazole.
C.   The tachycardia could be physiological, and treating it with a beta-blocker is unnecessary unless there is a more concerning underlying cause (like heart failure or ischemia). The priority here is not pharmacological intervention but monitoring the client's overall condition.
D.   This action allows for appropriate monitoring of the client's condition. Sinus tachycardia may resolve on its own without intervention, and the client doesn't exhibit severe symptoms requiring immediate pharmacologic treatment.

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Correct Answer is A

Explanation

A. Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B. Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C. Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D. Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.

A. Report the findings and anticipate a medical prescription for amiodarone B. Initiate a rapid response call and increase the monitor's sensitivity C. Start compressions and prepare for defibrillation D. Establish unresponsiveness and check the carotid pulse

Correct Answer is D

Explanation

A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.

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The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but complains of slight nausea after eating breakfast. What is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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