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 A

Explanation

A) Peaked T waves:
Peaked T waves are a classic sign of hyperkalemia on an EKG. As potassium levels rise, the T waves become taller, more pointed, and narrow, indicating changes in the heart's electrical conduction. This is one of the earliest and most characteristic EKG changes seen with hyperkalemia. Hyperkalemia can result from conditions such as kidney dysfunction, use of potassium-sparing diuretics, or other electrolyte imbalances.

B) Inverted P waves:
Inverted P waves typically suggest issues such as atrial ischemia or ectopic atrial rhythms but are not a hallmark sign of hyperkalemia. They may also appear with other conditions, like atrial fibrillation or atrial flutter. However, inverted P waves are not typically linked to elevated potassium levels.

C) Widened QRS:
A widened QRS complex can occur in several conditions, including hyperkalemia, but it is generally seen in more severe cases. As potassium levels rise further, the QRS complex may widen due to delayed conduction through the ventricles. Although a widened QRS can indicate hyperkalemia, it is a later sign, and it typically occurs after more specific changes like peaked T waves.

D) Prominent U wave:
Prominent U waves are more often associated with hypokalemia (low potassium levels) rather than hyperkalemia. U waves are typically seen after the T wave on the EKG and can be more prominent in conditions of low potassium.

A. Inability to void B. Unable to eat without thickening meals C. Loss of function in the lower extremity D. Difficulty breathing

Correct Answer is D

Explanation

A) Inability to void:
While urinary retention or difficulties with voiding can occur in ALS patients due to weakened muscles affecting the bladder, it is not the most immediate or life-threatening symptom that requires urgent attention. ALS primarily affects motor neurons and the voluntary muscles, and while autonomic dysfunction can lead to bladder or bowel issues, these are typically not the first concern in the acute phase of ALS unless they are severe.

B) Unable to eat without thickening meals:
Dysphagia (difficulty swallowing) is a common symptom in ALS, especially as the disease progresses and affects the muscles of the throat. While this symptom is important to address, it is manageable with interventions like speech therapy, modified diets, and thickened liquids

C) Loss of function in the lower extremity:
Loss of function in the lower extremities is a hallmark symptom of ALS as the disease progresses, but it is not an acute or life-threatening situation on its own. ALS leads to gradual muscle weakness and atrophy, particularly affecting voluntary motor functions.

D) Difficulty breathing:
As ALS progresses, respiratory muscles, including the diaphragm and intercostal muscles, weaken, which can lead to respiratory failure. The inability to breathe adequately can be life-threatening and may require interventions like mechanical ventilation, non-invasive positive pressure ventilation (BiPAP), or even a tracheostomy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the EKG strip of a client who is hypertensive and is complaining of muscle weakness. Which of the following abnormalities on the clients EKG should the nurse interpret as a sign of hyperkalemia?

Correct Answer is A

Explanation

The nurse is caring for a client who was recently diagnosed with ALS (Amyotrophic lateral sclerosis). Which of the following signs and symptoms is MOST important for the nurse to assess for?

Correct Answer is D

Explanation

A nurse working in the Neuro ICU is caring for a client who has been recently diagnosed with Guillain Barre Syndrome. Which of the following clinical manifestations should the nurse assess for?

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?

The nurse is caring for a client with uterine cancer who is being treated with brachytherapy. The UAP reports that the client ambulated to the restroom and is now reporting, "something feels like it’s coming out." What is the nurse's priority action?

A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?

A nurse is caring for a group of clients on a hospital unit with the assistance of a licensed practical nurse [LPN]. Which aspect of client care would be the most appropriate for the nurse to delegate to the LPN?

The nurse is preparing discharge teaching for a client with Bell's Palsy. Which of the following is most important to include in the teaching? [Select all that apply)