A client is to receive an intravenous dose of adenosine. What immediate response to this medication should the nurse expect?
Run of premature ventricular beats.
Short period of asystole.
Brief seizure episode.
Dramatic increase in blood pressure.
The Correct Answer is B
A. Run of premature ventricular beats: While adenosine can occasionally provoke brief ventricular ectopy, this is not its primary or most expected effect. Premature ventricular contractions may occur transiently but are not the hallmark response to this medication.
B. Short period of asystole: Adenosine briefly blocks AV node conduction and can interrupt re-entry pathways, often resulting in a short period of asystole lasting a few seconds. This is an expected effect and reflects the drug’s mechanism in terminating supraventricular tachycardia by interrupting the reentrant pathway.
C. Brief seizure episode: Adenosine does not typically cause seizures. It acts primarily on cardiac tissue and has no significant pro-convulsant effects. A seizure would be an atypical and concerning adverse reaction rather than an expected response.
D. Dramatic increase in blood pressure: Adenosine causes transient vasodilation and may lead to a brief drop in blood pressure or flushing. A dramatic increase in blood pressure would not be expected and could suggest an alternate diagnosis or drug reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Calculate the total volume to be infused in drops.
Total drops = Total volume (mL) × Drop factor (gtts/mL)
= 1000 mL × 60 gtts/mL
= 60000 gtts
Calculate the total infusion time in minutes.
Total infusion time (minutes) = Total hours × 60 minutes/hour
= 8 hours × 60 minutes/hour
= 480 minutes
Calculate the IV flow rate in drops per minute (gtts/min).
IV rate (gtts/min) = Total drops / Total infusion time (minutes)
= 60000 gtts / 480 minutes
= 125
=125 gtts/min
Correct Answer is B
Explanation
A. surgery has caused an episode of supraventricular tachycardia: While stress or surgery can trigger arrhythmias, the ECG shown demonstrates a sinus tachycardia pattern (narrow QRS complexes with identifiable P waves before each QRS), not supraventricular tachycardia (SVT), which typically has a very rapid, regular rhythm often without visible P waves.
B. is febrile which is causing the heart rate to be elevated: The client has a temperature of 102°F (38.8°C), which can increase metabolic demand and lead to sinus tachycardia. Fever is a common and expected cause of elevated heart rate, especially when accompanied by infection, such as the client’s post-op wound infection.
C. is in heart failure and the heart rate is elevated to compensate: There is no evidence from the scenario (no dyspnea, crackles, edema, or reduced BP) that supports heart failure. The elevated HR is more directly related to the fever and infection, not cardiac decompensation.
D. probably has a low oxygen saturation causing an increased respiratory rate: The respiratory rate is slightly elevated (22/min), but there is no mention of hypoxia or oxygen saturation levels. Tachycardia secondary to hypoxia would require clinical indicators of respiratory distress or desaturation, which are not demonstrated.
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