The nurse is interpreting cardiac monitoring on the rhythm below. What non-invasive priority action the nurse would take based on the rhythm?
Take the client's blood pressure.
Check the client's peripheral pulses.
Administer adenosine intravenous push (IVP) to the client.
Instructor the client to perform the Valsalva maneuver.
The Correct Answer is B
A. Take the client's blood pressure.: Measuring blood pressure is important for assessing perfusion, but it takes time and does not immediately assess the presence of a pulse or the client’s hemodynamic stability. In ventricular tachycardia (V-tach), rapid action is needed to determine if the client is perfusing before other interventions.
B. Check the client's peripheral pulses.: The first non-invasive priority is to assess whether the client has a palpable pulse, which determines if the V-tach is pulse-present (stable) or pulseless (unstable). This guides immediate interventions, such as preparing for synchronized cardioversion in a pulsed client or initiating CPR in a pulseless client. Assessing pulses quickly identifies life-threatening instability.
C. Administer adenosine intravenous push (IVP) to the client.: Adenosine is indicated for supraventricular tachycardia (SVT), not ventricular tachycardia. Administering adenosine in V-tach can worsen the arrhythmia or precipitate cardiac arrest.
D. Instruct the client to perform the Valsalva maneuver.: The Valsalva maneuver is used to terminate certain supraventricular tachycardias by increasing vagal tone. It is ineffective and unsafe for ventricular tachycardia, which originates in the ventricles and may rapidly deteriorate into ventricular fibrillation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Call the health care provider for a change in cardiac drugs: Notifying the provider is important for ongoing management, but the rhythm shown in the image is ventricular fibrillation (VF), which is immediately life-threatening. Delaying action to call the provider risks the client’s survival.
B. Place the client in a sitting position and administer oxygen: Positioning and oxygen may support a stable client with mild symptoms, but VF causes ineffective cardiac output, so interventions that only support oxygenation are insufficient. Immediate resuscitative measures are required.
C. Call the rapid response team to come and assess the client: While the rapid response team can assist, VF requires immediate intervention—delaying defibrillation and CPR while waiting for others significantly reduces survival chances.
D. Call a code and initiate cardiopulmonary resuscitation: Ventricular fibrillation is a pulseless, life-threatening arrhythmia that requires immediate activation of a code and initiation of CPR, followed by defibrillation. Early chest compressions and defibrillation are critical to restoring cardiac output and preventing sudden cardiac death.
Correct Answer is A
Explanation
A. Pericardial friction rub: Pericarditis is inflammation of the pericardial sac. The classic auscultatory finding is a high-pitched, scratchy pericardial friction rub heard best at the left lower sternal border. It is caused by the inflamed pericardial layers rubbing against each other and is a hallmark sign of pericarditis.
B. Mitral murmur: A mitral murmur is associated with mitral valve disorders such as mitral stenosis or mitral regurgitation, not inflammation of the pericardium.
C. Pleural friction rub: A pleural friction rub is heard with pleuritis and is related to lung and pleural inflammation. It is respiratory in origin and changes with breathing, unlike a pericardial friction rub.
D. S3 or S4: An S3 is commonly associated with heart failure, and an S4 is often linked to decreased ventricular compliance, such as in hypertension. These are not characteristic findings of acute pericarditis.
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