Nokea
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should be performed prior to defibrillating the client?
- A. Make sure the defibrillator is set to the synchronous mode
- B. Administer 1 mg of intravenous epinephrine
- C. Assess that everyone is clear of contact with the client and the bed
- D. Assess that everyone is clear of contact with the client and the bed
Correct Answer: D
Rationale: To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump is not indicated when a defibrillator is available. Epinephrine administration is part of advanced cardiac life support but is not the priority before defibrillation.
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A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?
- A. Administer oxygen therapy at 2 liters per nasal cannula
- B. Provide a sleeping aid prior to bedtime
- C. Schedule periods of exercise and rest during the day
- D. Ask unlicensed assistive personnel to help bathe the client
Correct Answer: C
Rationale: Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue when completing activities of daily living. The client should be encouraged to participate in self-care activities.
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?
- A. Administer a sedative to reduce anxiety
- B. Turn off oxygen therapy
- C. Ensure a tongue blade is available
- D. Position the client on their side
Correct Answer: B
Rationale: For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition.
- A. Sotalol (Betapace)
- B. Warfarin (Coumadin)
- C. Atropine (Sal-Tropine)
- D. Lidocaine (Xylocaine)
Correct Answer: B
Rationale: Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously, without treatment. Which statement should the nurse include in this client needs category.
- A. Minimize or abstain from caffeine
- B. Lie on your side until the attack subsides
- C. Use your oxygen when you experience PACs
- D. Take amiodarone (Cordarone) daily to prevent PACs
Correct Answer: A
Rationale: PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be used to control symptomatic dysrhythmias, for infrequent PACs, the client should first try lifestyle changes to control them.
A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip?
- A. Ventricular rhythm
- B. Ventricular fibrillation
- C. Sinus rhythm with premature atrial contractions (PACs)
- D. Sinus rhythm with premature ventricular contractions (PVCs)
Correct Answer: D
Rationale: Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precedes atrial depolarization. Ventricular dysrhythmias and ventricular fibrillation would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.