A nurse cares for a client who manifests Ventricular Tachycardia on a cardiac monitor. Which action should the nurse take first?
Prepare the defibrillator for potential use.
Call the physician for further instructions.
Assess the client's airway, breathing, and circulation.
Administer antiarrhythmic medication.
The Correct Answer is C
Rationale:
A. While defibrillation may be necessary, it should not be the first action. Immediate assessment determines whether the client is pulseless or unstable, which guides the appropriate intervention.
B. Delaying assessment to contact the provider could waste critical time, especially in life-threatening arrhythmias like VT. Nurses must act immediately according to the patient’s condition and protocols.
C. The first action in any suspected life-threatening arrhythmia is to assess the patient’s ABCs. This assessment determines hemodynamic stability and guides whether to perform CPR, defibrillation, or prepare for cardioversion, prioritizing patient safety.
D. Antiarrhythmic drugs may be indicated after assessment and determination of stability, but they are not the initial intervention. Immediate evaluation of ABCs is required to prevent deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Amylase is an enzyme primarily elevated in pancreatic disorders such as pancreatitis, not myocardial infarction.
B. Unconjugated bilirubin is elevated in hemolysis or liver dysfunction. It is not a marker of myocardial injury.
C. AST can be elevated after myocardial infarction, but it is nonspecific because it is also found in liver, skeletal muscle, and kidneys. It rises later and is not the most sensitive early marker.
D. Troponin I is highly specific to cardiac muscle injury and increases within 3–6 hours after myocardial infarction, making it a primary early diagnostic marker. It remains elevated for 7–10 days, helping confirm myocardial injury.
Correct Answer is ["B","D"]
Explanation
Rationale:
A. LDL cholesterol levels are used to assess a patient’s long-term risk for atherosclerosis and cardiovascular disease, but they do not rise acutely during myocardial infarction and therefore are not useful for diagnosing an MI in the emergency setting.
B. Myoglobin is a small heme protein released rapidly from damaged cardiac and skeletal muscle. It can appear in the blood within 1–4 hours after myocardial injury, making it useful for early detection of myocardial infarction. However, it is not specific to cardiac muscle, so elevations could also occur with skeletal muscle injury. Myoglobin is often used in conjunction with other cardiac biomarkers.
C. Blood urea nitrogen reflects renal function and may increase in kidney disease or dehydration, but it does not indicate myocardial injury and is not part of the standard diagnostic workup for acute MI.
D. Troponin I and T are structural proteins of cardiac muscle, and their levels rise within 3–6 hours after myocardial injury and remain elevated for up to 10–14 days. They are highly sensitive and specific for cardiac injury, making troponin the gold standard for confirming myocardial infarction.
E. Creatinine measures kidney function and may be monitored in patients receiving contrast dye or nephrotoxic drugs, but it does not aid in diagnosing an acute MI.
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