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After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: [Vital signs data]. Based on the assessments, which action should the nurse take?
- A. Stop the infusion and flush the IV
- B. Slow the amiodarone infusion rate
- C. Administer IV normal saline
- D. Ask the client to cough and deep breathe
Correct Answer: B
Rationale: IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly stopping the medication could allow fatal dysrhythmias to occur.
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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
- A. Mid-sternal chest pain
- B. Increased urine output
- C. Mild orthostatic hypotension
- D. P wave touching the T wave
Correct Answer: A
Rationale: Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates tachycardia and should be assessed to determine the underlying rhythm and cause, but this is not as critical as chest pain, which indicates cardiac cell death.
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 Beats/min. What should the nurse assess? (Select all that apply.)
- A. Decrease in cardiac output
- B. Increase in cardiac output
- C. Increase in cardiac output
- D. Increase in blood pressure
- E. Decrease in urine output
- F. Increase in urine output
Correct Answer: A,D,E
Rationale: Tachycardia may initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall.
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 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.
The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below. After calling for assistance and a defibrillator, which action should the nurse take next?
- A. Perform a pericardial thump
- B. Initiate cardiopulmonary resuscitation (CPR)
- C. Start an 8-gauge intravenous line
- D. Ask the clients family about code status
Correct Answer: B
Rationale: The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. The pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to the event.