The nurse is notified by the telemetry monitor tech that the client has been persistently in the following rhythm [see image). The client has a exhibiting the following cardiac rhythm? pulse of 130 bpm, B/P of 86/44 mm Hg, respirations of 24 with a saturation of 90%. Which of the following is a priority intervention for a client exhibiting the following cardiac rhythm?

Obtain blood specimen for a BMP test.

Prepare for synchronize cardioversion

Start CPR

Prepare for defibrillation

Answer and Explanation

The Correct Answer is B

A) Obtain blood specimen for a BMP test:
Although obtaining laboratory tests like a BMP (Basic Metabolic Panel) can be important in evaluating the client’s electrolyte balance and kidney function, it is not the priority intervention in this acute situation. The client is exhibiting a potentially dangerous rhythm and the immediate intervention to stabilize the rhythm is necessary before ordering lab tests.

B) Prepare for synchronized cardioversion:
The priority intervention for a client exhibiting this cardiac rhythm with accompanying signs of hemodynamic instability (low blood pressure, tachycardia, respiratory distress) is synchronized cardioversion. This is especially the case if the rhythm is atrial fibrillation, atrial flutter, or supraventricular tachycardia (SVT), which can be life-threatening if not treated promptly. Synchronized cardioversion is indicated when the patient is symptomatic and hemodynamically unstable.

C) Start CPR:
While starting CPR is critical for a patient who is unresponsive and in a pulseless rhythm (such as ventricular fibrillation or asystole), this client is still responsive with a pulse of 130 bpm. Although the client is in a high-risk rhythm with signs of hemodynamic instability, CPR is not indicated at this moment because the client is not in cardiac arrest.

D) Prepare for defibrillation:
Defibrillation is indicated for life-threatening arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. In this case, the client has a pulse, indicating that defibrillation is not appropriate.

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Correct Answer is C

Explanation

A) Retake the vital signs:
While taking vital signs is important, the client’s vital signs (respiratory rate of 13 bpm, oxygen saturation of 92%, and normal skin color) suggest that there is no immediate crisis, such as a sudden drop in oxygen saturation or significant hemodynamic instability. Therefore, retaking the vital signs would not address the most urgent issue at the moment, which is the client's shortness of breath while laying down.

B) Call the healthcare provider:
Calling the healthcare provider may eventually be necessary if the patient's condition worsens or remains unrelieved after interventions. However, the first priority should be to manage the client’s immediate symptoms and improve their comfort. The client’s complaint of shortness of breath when lying down suggests that the positioning may be a contributing factor to their discomfort.

C) Place the client in Fowler's position:
The most appropriate first action for a client with end-stage COPD and shortness of breath while lying down is to place the client in Fowler's position. This position (sitting upright, typically at a 45-60° angle) helps to improve lung expansion and reduce the workload of breathing by using gravity to assist in lung ventilation. It also promotes diaphragmatic breathing, which can relieve the feeling of breathlessness.

D) Increase the oxygen rate:
The client is already on 6 liters of oxygen via nasal cannula and has an oxygen saturation of 92%, which is within an acceptable range for a patient with COPD. Increasing the oxygen rate further could risk causing oxygen toxicity or lead to CO2 retention in clients with COPD, as their respiratory drive is often driven by low oxygen levels rather than high carbon dioxide levels. Thus, increasing the oxygen rate should be done cautiously and only if clinically indicated by a healthcare provider.

A. A normal finding. B. A myasthenia gravis crisis due to drug undermedication C. An allergic reaction. D. A cholinergic crisis due to drug overmedication

Correct Answer is D

Explanation

A) A normal finding:
A normal finding during an edrophonium (Tensilon) test is an improvement in muscle strength for clients with myasthenia gravis (MG). If the client becomes weaker after the dose, it indicates that the test results are not typical and suggest a different issue, not a normal response. This is not a normal finding.

B) A myasthenia gravis crisis due to drug undermedication:
In a myasthenic crisis, the client experiences severe weakness and respiratory difficulty, typically due to insufficient medication (e.g., pyridostigmine). While a myasthenic crisis could cause weakness and respiratory distress, the edrophonium test would typically show improvement in muscle strength if the crisis is due to undermedication. Since the client became weaker after receiving edrophonium, this is not indicative of a myasthenic crisis.

C) An allergic reaction:
An allergic reaction to the edrophonium test would typically result in symptoms such as rash, swelling, or difficulty breathing due to hypersensitivity, but it does not typically cause weakness as the primary response. The worsening of symptoms after the test is more likely related to drug overmedication rather than an allergic reaction.

D) A cholinergic crisis due to drug overmedication:
A cholinergic crisis occurs when there is an overdose of acetylcholinesterase inhibitors (e.g., pyridostigmine or neostigmine), which can lead to excessive acetylcholine at the neuromuscular junction, resulting in muscle weakness and respiratory failure. The edrophonium test helps differentiate between a myasthenic crisis and a cholinergic crisis. If the client becomes weaker after the administration of edrophonium, it suggests a cholinergic crisis due to drug overmedication.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with history of myasthenia gravis is experiencing prolonged periods of weakness and difficulty breathing. The provider orders an edrophonium [Tensilon] test. Once the dose is administered, the client becomes weaker. The nurse interprets this test result as:

Correct Answer is D

Explanation

A nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

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