The nurse reviews data from the cardiac monitor indicating that a patient with a myocardial infarction experienced a 50 second episode of ventricular tachycardia before a sinus rhythm and heart rate of 98 were re-established. The most appropriate initial action by the nurse is to
defibrillate the patient.
cardiovert the patient.
document the rhythm and continue to monitor the patient.
administer IV antidysrhythmic drugs per protocol.
The Correct Answer is C
A. Defibrillate the patient: Defibrillation is indicated for pulseless ventricular tachycardia or ventricular fibrillation. Since the patient’s rhythm spontaneously returned to sinus with a stable heart rate and no signs of hemodynamic compromise, immediate defibrillation is not warranted.
B. Cardiovert the patient: Synchronized cardioversion is used for unstable tachydysrhythmias with a pulse causing hypotension, chest pain, or altered mental status. This patient is stable after the VT episode, so cardioversion is unnecessary at this time.
C. Document the rhythm and continue to monitor the patient: The patient experienced a self-limiting episode of ventricular tachycardia that resolved spontaneously. The priority is to document the event, assess the patient for symptoms or complications, and continue close monitoring for recurrence, which allows timely intervention if instability develops.
D. Administer IV antidysrhythmic drugs per protocol: Antidysrhythmic therapy may be indicated if VT recurs or becomes sustained and symptomatic. Since this episode terminated spontaneously and the patient is hemodynamically stable, immediate drug administration is not required but may be considered for prophylaxis or with provider orders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Low-sodium diet: A low-sodium diet is often prescribed for cardiac patients to help control fluid retention and blood pressure. This prescription is appropriate and does not interfere with pacemaker function.
B. MRI of the chest: Many permanent pacemakers are not MRI-compatible due to the risk of lead heating, device malfunction, or movement of the generator. Ordering an MRI of the chest after pacemaker insertion requires clarification to prevent serious device-related complications. Alternative imaging modalities or MRI-compatible devices should be confirmed first.
C. Physical therapy: Early mobilization and physical therapy are typically encouraged post-pacemaker insertion to maintain overall function and prevent deconditioning. Precautions regarding the affected arm may apply, but physical therapy is generally safe and appropriate.
D. Serum cardiac enzyme levels: Monitoring cardiac enzymes can help assess for perioperative myocardial injury, particularly if the patient had underlying cardiac disease or post-procedural complications. This prescription is safe and does not conflict with pacemaker care.
Correct Answer is A
Explanation
A. Have the client lie flat in bed with leg straight: After a cardiac catheterization, especially via the femoral artery, it is critical to keep the affected leg straight and the patient supine to prevent bleeding or hematoma formation at the puncture site. This positioning minimizes stress on the arterial access site and supports proper hemostasis during the immediate post-procedure period.
B. Keep the affected leg slightly flexed: Flexing the leg can increase pressure on the arterial puncture site, potentially causing bleeding, hematoma, or pseudoaneurysm formation. Maintaining the leg in a straight position is essential for vascular integrity and patient safety.
C. Elevate the head of the bed 45°: Elevating the head too early can increase hydrostatic pressure at the catheter insertion site, raising the risk of bleeding. Initial post-catheterization care requires a flat position until hemostasis is secure and vascular stability is confirmed.
D. Keep the client NPO for 4 hr: NPO status is typically not required after cardiac catheterization unless sedation or contrast-related concerns exist. Early resumption of oral intake is often safe and encouraged once the patient is alert and stable, as prolonged fasting is unnecessary and may cause discomfort.
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