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) Take the medication with meals:
Inhaled beclomethasone is a corticosteroid, and it is generally not necessary to take it with meals. Oral corticosteroids are sometimes taken with meals to minimize gastric irritation, but this does not apply to inhaled corticosteroids like beclomethasone. The primary concern with inhaled corticosteroids is not related to meal timing but to oral hygiene to prevent side effects like oral thrush.

B) Limit caffeine intake:
There is no direct contraindication or requirement to limit caffeine intake when taking inhaled beclomethasone. While caffeine can have mild bronchodilatory effects, it does not interfere with the action of beclomethasone or exacerbate asthma symptoms. This is not a priority teaching point for the patient.

C) Rinse the mouth after administration:
One of the most important teaching points when using inhaled beclomethasone is to rinse the mouth after each use. This helps to prevent oral thrush (a fungal infection caused by Candida), which is a common side effect of inhaled corticosteroids. Rinsing the mouth with water after administration helps to remove any leftover medication and reduce the risk of infection, making this the most important instruction.

D) Check the pulse before and after medication administration:
While checking the pulse is important for some medications, such as bronchodilators like albuterol, it is not necessary for inhaled beclomethasone. Beclomethasone is a corticosteroid that primarily works by reducing inflammation in the airways, and it does not have a significant impact on heart rate. Therefore, it is not required to monitor pulse before and after its use.

A. Hypertension B. Indigestion C. Eupnea D. Irregular palpitations

Correct Answer is D

Explanation

A. Hypertension:

Hypertension is not directly related to the rhythm displayed in the image. The rhythm is suggestive of atrial fibrillation (AF), characterized by irregular and chaotic electrical activity, leading to irregular heartbeats. Hypertension can be a risk factor for AF but is not a typical presenting symptom.

B. Indigestion:

Indigestion is a non-specific symptom that may occur in cardiac events like myocardial infarction but is not a hallmark of atrial fibrillation. The rhythm strip does not indicate myocardial ischemia.

C. Eupnea:

Eupnea refers to normal breathing, which is not commonly associated with atrial fibrillation. Clients with AF may experience symptoms such as shortness of breath or fatigue rather than normal, unlabored breathing.

D. Irregular palpitations:

This is the most expected finding. Atrial fibrillation leads to an irregularly irregular pulse, which patients often describe as palpitations. This rhythm strip demonstrates the hallmark chaotic atrial activity and irregular ventricular response seen in AF.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge teaching for a client with asthma that has been prescribed inhaled beclomethasone. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A client with the rhythm below has been admitted into the cardiac icu. What assessment finding does the nurse expect to find in this client?

Correct Answer is D

Explanation

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