A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia. Which interventions are most appropriate and should be included in the client's plan of care? (SELECT ALL THAT APPLY)
Prevention of vagal stimulation
Assess for acute pain
Prevention of falls
Assess for neurologic changes
Monitor fluid volume excess
Correct Answer : A,C,D
Rationale:
A. Preventing vagal stimulation can help prevent bradycardia.
B. Acute pain is not typically associated with sinus bradycardia.
C. Preventing falls is important because bradycardia can lead to dizziness and falls.
D. Assessing for neurologic changes is important because bradycardia can affect cerebral perfusion.
E. Monitoring fluid volume excess is not directly related to sinus bradycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Elevated Troponins indicate myocardial injury or infarction.
B. Elevated Creatine kinase (CK) is an enzyme found in skeletal muscle, brain, and myocardium. Elevated levels can indicate muscle damage.
C. Elevated Hemoglobin is not specific to cardiac injury.
D. Elevated B-type Natriuretic peptide (BNP) is used in the diagnosis and management of heart failure.
Correct Answer is D
Explanation
Rationale:
A. Synchronized cardioversion is not appropriate for pulseless ventricular tachycardia.
B. A repeat ECG is not necessary for pulseless ventricular tachycardia.
C. Assessment of blood pressure is not the priority in pulseless ventricular tachycardia.
D. Immediate defibrillation is the priority in pulseless ventricular tachycardia to restore a perfusing rhythm.
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