Nokea
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.
You may also like to solve these questions
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.
The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should expect the client to demonstrate which clinical manifestation in conjunction with this electrocardiogram tracing? See the exhibit.
- A. Jugular venous distention (JVD)
- B. Systolic murmur
- C. Irregular pulse
- D. Widened pulse pressure
Correct Answer: C
Rationale: An irregular ECG tracing, such as in atrial fibrillation, typically correlates with an irregular pulse due to inconsistent ventricular contractions.
The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will need to take antibiotics for one week following this test.
- B. This test will determine if I have any blood clots in my heart.
- C. I will receive general anesthesia for this procedure.
- D. I may feel a flushing sensation when the contrast dye is given.
Correct Answer: B
Rationale: TEE is used to detect intracardiac thrombi, such as in atrial fibrillation, making this statement correct.
The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?
- A. Positive pressure ventilation
- B. Pericardiocentesis
- C. Echocardiography
- D. 0.9% saline bolus
Correct Answer: A
Rationale: Positive pressure ventilation can worsen cardiac tamponade by further compressing the heart, so it should be clarified.
The nurse cares for a client with acute myocardial infarction (AMI). The nurse anticipates the physician will order an emergent
- A. exercise electrocardiography.
- B. computed tomography (CT) of the chest with contrast.
- C. percutaneous coronary intervention (PCI).
- D. echocardiogram.
Correct Answer: C
Rationale: PCI is the standard emergent treatment for AMI to restore coronary blood flow.