Nokea
The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse. The nurse should implement which priority treatment based on the tracing
- A. Start cardiopulmonary resuscitation (CPR)
- B. Perform immediate defibrillation
- C. Initiate intravenous (IV) access
- D. Review the client's most recent electrolyte levels
Correct Answer: B
Rationale: Pulseless ventricular fibrillation or tachycardia requires immediate defibrillation to restore rhythm.
You may also like to solve these questions
The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis?
- A. I notice that my feet are always swollen.
- B. I can't seem to get rid of this wet cough.
- C. I develop shortness of breath after I walk a few feet.
- D. My legs start to burn if I walk long distances.
Correct Answer: A
Rationale: Right ventricular heart failure causes systemic venous congestion, leading to peripheral edema, such as swollen feet.
The nurse is caring for a client with myocardial infarction (MI), who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Observe for signs of bleeding
- D. Check the client's food diary
Correct Answer: C
Rationale: tPA is a thrombolytic that increases bleeding risk. Monitoring for signs of bleeding (e.g., hematoma, gastrointestinal bleeding) is critical.
The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidence by the client's
- A. hypertension.
- B. bronchodilation.
- C. increase in heart rate (HR).
- D. decrease in heart rate (HR).
Correct Answer: D
Rationale: A vasovagal response causes bradycardia due to vagal nerve stimulation during procedures like bronchoscopy.
Which of the following heart sounds would the nurse expect to auscultate in a client with systolic heart failure? Select all that apply.
- A. S1
- B. S2
- C. S3
- D. S4
- E. Pleural friction rub
Correct Answer: C
Rationale: S1 is a normal heart sound. B: Incorrect - S2 is a normal heart sound. C: Correct - S3 is associated with systolic heart failure due to rapid ventricular filling. D: Incorrect - S4 is linked to diastolic dysfunction, not systolic failure. E: Incorrect - Pleural friction rub indicates pleural inflammation, not heart failure.
The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) is caring for a 41-year-old male client.
Item 1 of 1
Progress Notes
1544: Received client to ICU immediately following percutaneous transluminal coronary angioplasty followed by stenting via right femoral artery. Notified primary health care provider about client status. Awaiting orders.
The nurse contacts the primary healthcare provider for admission orders
For each potential order, click to specify whether the potential order is indicated or not indicated for the client post-percutaneous transluminal coronary angioplasty.
- A. Head of the bed elevated up to 30 degrees
- B. Elevate the right leg on a pillow
- C. Continuous cardiac monitoring
- D. Serial troponin levels
- E. Keep the client NPO
- F. Obtain serum glucose levels every two hours
Correct Answer: A,C,D,F
Rationale: A: Indicated - Elevating the head of the bed promotes comfort and reduces cardiac workload. B: Not indicated - Elevating the leg is not standard post-angioplasty unless specified for complications. C: Indicated - Continuous monitoring detects arrhythmias post-procedure. D: Indicated - Serial troponin levels monitor for myocardial injury. E: Not indicated - NPO status is typically temporary and not required post-procedure unless specified. F: Indicated - Glucose monitoring is crucial for diabetic patients or those at risk post-procedure.