Nokea
The nurse assesses the following telemetry strip for a client on a medical-surgical unit. Based on the rhythm, what is the priority action for the nurse to take? See the exhibit.
- A. Prepare for synchronized cardioversion
- B. Obtain a prescription for intravenous (IV) atropine
- C. Review the client's most recent labs
- D. Assess if the client has a carotid pulse (P)
Correct Answer: D
Rationale: A life-threatening rhythm (e.g., ventricular tachycardia) requires immediate assessment of pulse to determine if the client is stable or needs resuscitation.
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A hypertensive client was prescribed antihypertensive medication. The client tells a clinic nurse that she prefers to take an herbal supplement to help lower her blood pressure. Which is the most appropriate response from the nurse?
- A. Tell the client that herbal supplements are unsafe and should be avoided
- B. Encourage the client to discuss the use of herbal supplements with her attending health care provider (HCP)
- C. Teach the client how to take her blood pressure and ask her to monitor it every fifteen minutes
- D. Tell the client that if she takes the herbal supplement, it will require the nurses to monitor her blood pressure closely
Correct Answer: B
Rationale: Herbal supplements can interact with medications, so discussing with the HCP ensures safety and efficacy.
The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as
- A. a widened pulse pressure.
- B. a pulse deficit.
- C. pulsus paradoxus.
- D. an expected finding.
Correct Answer: B
Rationale: A difference between apical and radial pulses indicates a pulse deficit, often due to weak or missed beats.
The nurse should be prepared to obtain which prescription from the primary healthcare provider for a client with an oral temperature of 101 ° F (38.3° C) and an ECG tracing? Select all that apply.
- A. 0.9% saline bolus
- B. Enalapril
- C. Levothyroxine
- D. Metoclopramide
- E. Acetaminophen
Correct Answer: E
Rationale: Saline bolus is not indicated for fever alone without dehydration. B: Incorrect - Enalapril is for hypertension or heart failure, not fever or ECG issues. C: Incorrect - Levothyroxine is for hypothyroidism, not relevant here. D: Incorrect - Metoclopramide is for nausea, not fever or cardiac issues. E: Correct - Acetaminophen is appropriate for fever reduction.
The nurse cares for a client with a complete (3rd-degree) heart block and hypotension. The nurse should take which appropriate action?
- A. prepare the client for temporary transcutaneous pacing
- B. obtain a prescription for an esmolol infusion
- C. begin chest compressions
- D. instruct the client to perform the Valsalva maneuver
Correct Answer: A
Rationale: Complete heart block with hypotension requires urgent pacing to restore adequate heart rate and cardiac output.
Which interventions would be appropriate for a client with decreased cardiac output? Select all that apply.
- A. Apply compression stockings
- B. Obtain a prescription for nitroglycerin via transdermal patch
- C. Elevate the client's legs
- D. Implement fall precautions
- E. Educate the client about not straining when defecating
Correct Answer: A,D,E
Rationale: Compression stockings improve venous return, supporting cardiac output. B: Incorrect - Nitroglycerin reduces preload, potentially worsening cardiac output in some cases. C: Incorrect - Leg elevation is not standard for low cardiac output and may worsen symptoms. D: Correct - Fall precautions are needed due to potential weakness or syncope. E: Correct - Avoiding straining prevents Valsalva maneuver, which can reduce cardiac output.