Nokea
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
- A. Prepare for transcutaneous pacing.
- B. Prepare to defibrillate the client at 200 joules.
- C. Administer atropine 0.5 mg I.V. push.
- D. Schedule the operating room for insertion of a permanent pacemaker.
Correct Answer: A
Rationale: Third-degree heart block with a rate of 35 bpm and hypotension requires immediate transcutaneous pacing to restore adequate heart rate and perfusion.
You may also like to solve these questions
The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to:
- A. Immerse her hands in cold water during an episode
- B. Wear light garments when the temperature gets below 50°F (10°C)
- C. Wear gloves when handling ice or frozen foods
- D. Live in a cold climate
Correct Answer: C
Rationale: Wearing gloves when handling ice or frozen foods prevents cold-induced vasospasm in Raynaud's. Cold water worsens symptoms, light garments are insufficient in cold temperatures, and living in a cold climate increases episode frequency.
The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity?
- A. constricted pupils
- B. hypertension
- C. coarse Tremors
- D. diarrhea
Correct Answer: A
Rationale: Constricted pupils (miosis) are a hallmark of opioid toxicity, including fentanyl, due to its effects on the central nervous system.
The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following?
- A. External hemorrhage.
- B. Decreasing level of consciousness.
- C. Laryngeal nerve damage.
- D. Upper airway obstruction.
Correct Answer: C
Rationale: Asking the client to speak monitors for laryngeal nerve damage, which can cause vocal cord paralysis and hoarseness, a potential complication of thyroidectomy.
Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication?
- A. Increase the amount of potassium in the diet.
- B. Maintain a regular program of weight-bearing exercise.
- C. Limit dietary vitamin D intake.
- D. Perform isometric exercises.
Correct Answer: B
Rationale: Weight-bearing exercise promotes bone density, counteracting bone resorption caused by excess cortisol in Cushing's disease.
What is the nurse's best action for a client with a C6 spinal cord injury?
- A. Assess respiratory status.
- B. Check bladder function.
- C. Monitor skin integrity.
- D. Evaluate motor strength.
Correct Answer: A
Rationale: Assessing respiratory status is the priority due to potential diaphragmatic impairment in a C6 injury.