A client who is on the progressive care unit develops supraventricular tachycardia (SVT). The clients vital signs: T: 98, HR: 160, BP: 119/71, RR: 19, Sp02 94% on RA. The client presents with no dyspnea, shortness of breath or chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first?

Perform immediate defibrillation.

Perform immediate cardioversion.

Administer Adenosine 6 mg IVP.

Administer Adenosine 12 mg IVP.

Answer and Explanation

The Correct Answer is C

A. Defibrillation is used for life-threatening arrhythmias like ventricular fibrillation or pulseless ventricular tachycardia, not for SVT.

B. Cardioversion is appropriate for certain arrhythmias, but in this case, SVT with a stable pulse can be treated initially with medication like adenosine.

C. Adenosine is the first-line treatment for SVT. The typical starting dose is 6 mg IVP, which can be repeated if necessary. Adenosine works by temporarily blocking the electrical conduction through the AV node, allowing the heart to reset to a normal rhythm.

D. A 12 mg dose of Adenosine is used if the 6 mg dose is ineffective, but the 6 mg dose is typically administered first.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Epinephrine is used in cases of severe allergic reactions or anaphylaxis, and while it may be appropriate in treating angioedema, the first priority is to ensure the airway is clear and that the client can breathe. Administering epinephrine may be part of the treatment plan but should follow securing the airway and calling for immediate advanced help.

B. This is not appropriate because angioedema can be life-threatening and can rapidly progress to airway obstruction. Reassurance without action would delay necessary interventions and could jeopardize the client’s safety.

C. In cases of angioedema, airway obstruction is the most dangerous complication, as it can lead to asphyxiation. The nurse's first priority is to ensure that the patient's airway remains open and clear. The nurse should immediately call the Rapid Response Team (RRT) for urgent medical intervention, which may include medications (like epinephrine), intubation, or other interventions. Ensuring the airway is open and calling for advanced help are the most critical first steps in managing severe cases of angioedema.

D. While oxygen therapy may be appropriate if the client shows signs of respiratory distress or hypoxia, the immediate concern is securing the airway. Oxygen may be needed after ensuring the airway is open, but the priority is to avoid airway obstruction first. The nurse should secure the airway and then administer oxygen if needed.

A. Client with a blood pressure of 90/50 mm Hg. B. Client with a temperature of 96° F (35.6° C). C. Client with a pulse of 118 beats/min. D. Client with a respiratory rate of 6 breaths/min.

Correct Answer is D

Explanation

A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

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Naxlex Comprehensive Predictor Exams

A client is in the hospital and has received two doses of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below. What action by the nurse is most appropriate?

Correct Answer is C

Explanation

The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

Correct Answer is D

Explanation

After receiving change-of-shift report, which client should the nurse assess first?

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A client admitted to a medical - surgical unit has a CBC with differential drawn. Lab results show a WBC count of 4000, with neutrophil segments at 5% and neutrophil bands at 5%. Based on these values what would the nurse do? Calculate the absolute neutrophil count

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