A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Perform carotid massage on the client

Administer adenosine 12mg IV push STAT

Prepare the client for electrical cardioversion

Assess patient and obtain vital signs

Answer and Explanation

The Correct Answer is D

A.   Carotid massage can be used as a vagal maneuver for certain types of supraventricular tachycardia (SVT), particularly in stable patients. However, it is not recommended in cases where the patient has a history of cocaine use or is showing signs of instability because of the potential for triggering a serious event, like a stroke.
B.   Adenosine is a medication commonly used for the treatment of SVT. However, it should be given with caution and only after assessing the patient's condition. In this case, the patient needs to be assessed first, including vital signs, level of consciousness, and overall stability, before any medications are administered.
C.   Electrical cardioversion is indicated for unstable SVT (e.g., signs of hemodynamic instability such as hypotension, chest pain, or altered mental status). However, this patient is only reporting a "racing heart" and nervousness and has not yet been assessed for vital signs or other clinical symptoms.
D.   The first step in this case should be to assess the patient's condition. This includes checking the vital signs, level of consciousness, and overall stability. Once this initial assessment is performed, the nurse can then determine whether medications or other interventions (like adenosine or cardioversion) are needed.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B. Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C. Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D. Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.

A. A- B. АB C. O- D. A- E. O+

Correct Answer is ["A","C","D"]

Explanation

A. A patient with blood type A- can receive A- blood, as it matches both the ABO blood group and Rh factor.
B. A patient with A- blood cannot receive AB blood because the blood type is incompatible in terms of both ABO group and Rh factor. AB blood contains both A and B antigens, which could lead to an immune response in a type A patient.
C. O- blood is a universal donor for all blood types, meaning it does not contain A or B antigens and does not have the Rh factor, so it can be given to an A- patient.
D. As already noted, A- blood is compatible with an A- patient because both the ABO group and Rh factor are the same.
E. O+ blood contains the Rh antigen, and since the patient is A-, they cannot receive Rh-positive blood, as this could cause an immune reaction.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

Correct Answer is A

Explanation

The nurse is caring for a patient whose blood type is A-. The nurse knows that this patient can receive the following blood types:(SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D"]

Explanation

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