Nokea
The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below.
- A. Assess the client's level of consciousness
- B. Prepare the client for immediate defibrillation
- C. Administer a dose of intravenous epinephrine
- D. Evaluate the client's cardiac lead placement
Correct Answer: B
Rationale: A life-threatening rhythm like ventricular fibrillation requires immediate defibrillation to restore normal rhythm.
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Which of the following information should the nurse include when teaching a client about congestive heart failure (CHF)? Select all that apply.
- A. Foods such as canned vegetables and luncheon meat should be avoided.
- B. Weigh yourself daily and notify the physician if the weight gain is more than ten pounds in a week.
- C. You may continue to take ibuprofen for your aches and pains.
- D. Annual immunizations such as the influenza vaccine are recommended.
- E. If you feel sick, you will need to check your urine for ketones.
Correct Answer: A,D
Rationale: High-sodium foods like canned vegetables and luncheon meat should be avoided to prevent fluid retention. B: Incorrect - Weight gain >2-3 lbs in a week is concerning, not 10 lbs. C: Incorrect - Ibuprofen can worsen heart failure. D: Correct - Influenza vaccine reduces infection risk, which can exacerbate heart failure. E: Incorrect - Checking urine for ketones is relevant for diabetes, not CHF.
Which of the following statements by the client with atrial fibrillation would require a follow-up? Select all that apply.
- A. I have an increased risk for a stroke.
- B. I should weigh myself daily at the same time.
- C. I may be prescribed medications such as amiodarone.
- D. I should wear a mask when I am in public.
- E. I should seek medical care if I develop shortness of breath.
Correct Answer: B,D
Rationale: Atrial fibrillation increases stroke risk due to clot formation; no follow-up needed. B: Incorrect - Daily weighing is more relevant for heart failure, not atrial fibrillation; requires clarification. C: Correct - Amiodarone is a common medication for atrial fibrillation; no follow-up needed. D: Incorrect - Wearing a mask in public is not related to atrial fibrillation management; requires clarification. E: Correct - Shortness of breath could indicate complications; no follow-up needed.
The nurse is assessing a client's cardiac rhythm strip and notices that it is irregular without any P waves before the QRS complexes. The nurse should interpret this as
- A. sinus tachycardia.
- B. sinus bradycardia.
- C. normal sinus rhythm with premature ventricular contractions (PVC).
- D. atrial fibrillation
Correct Answer: D
Rationale: Atrial fibrillation is characterized by an irregular rhythm and absent P waves due to chaotic atrial activity.
The nurse is caring for a client with atrial fibrillation. Which of the following client findings requires immediate follow-up by the nurse?
- A. Irregular QRS complexes on telemetry reading
- B. Irregular peripheral pulse
- C. Reports of intermittent palpitations
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision may indicate a stroke, a serious complication of atrial fibrillation due to thromboembolism.
The nurse is performing an assessment on a client with congestive heart failure demonstrating ineffective coping. The nurse should plan to
- A. recommend a support group.
- B. review dietary items low in sodium.
- C. review the client's vaccination status.
- D. recommend the client take St. John's Wort.
Correct Answer: A
Rationale: A support group addresses ineffective coping by providing emotional support and coping strategies.