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.

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

Rationale:

A. While pneumonia can cause fever, fatigue, and chest discomfort, it is less likely to cause severe pedal edema, irregular heart rhythms, or palpitations. The presence of edema and irregular heart sounds points toward a cardiac origin rather than a primary pulmonary infection.

B. Fatigue, chest discomfort, irregular heart sounds, pedal edema, and low blood pressure are classic signs of heart failure, particularly in a young adult who may have acute or chronic cardiac dysfunction. Heart failure can also contribute to the development of arrhythmias.

C. COPD primarily presents with chronic cough, dyspnea, and sputum production. While it can strain the heart over time, COPD alone would not account for the acute irregular heart rate, edema, and chest discomfort in this patient.

D. The irregular heart rate (HR 112 bpm) and irregular heart sounds are indicative of atrial fibrillation, which is common in patients with underlying heart disease or heart failure. Atrial fibrillation can also worsen cardiac output, contributing to edema and fatigue.

E. Pulmonary embolism typically presents with acute dyspnea, pleuritic chest pain, tachypnea, and sometimes hemoptysis. Edema and irregular heart rhythms are not primary features, making this less likely than heart failure and atrial fibrillation.

A. Document the findings and continue with the visit. B. Ensure the client has been taking their prescribed diuretic. C. Reinforce the importance of daily weights. D. Call the health care provider for further instructions.

Correct Answer is D

Explanation

Rationale:

A. While documentation is important, a weight gain of ≥2 lb (≈1 kg) in 1–3 days and generalized edema indicates fluid retention and possible worsening heart failure, which requires immediate provider notification, not just documentation.

B. Although adherence to diuretics is important, simply confirming this does not address the acute risk of fluid overload and possible decompensation. Immediate action is required.

C. Education is important for prevention, but in this case, the patient is already showing signs of worsening heart failure, so reinforcing education alone is insufficient.

D. Rapid weight gain and generalized edema over a short period are red flags for fluid overload. The nurse should contact the provider immediately to report findings and receive guidance for interventions such as adjusting medications, evaluating for hospitalization, or further monitoring.

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A nurse cares for a client who manifests Ventricular Tachycardia on a cardiac monitor. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 22-year-old patient presents with fatigue, chest discomfort, and palpitations. Vital signs show HR 112 bpm. BP 98/5, and low-grade fever. The nurse notes irregular heart sounds and severe pedal edema. Which condition should the nurse suspect? (Select All that Apply.)

Correct Answer is ["B","D"]

Explanation

A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema. since the last visit 3 days ago. Which of the following actions should the nurse take next?

Correct Answer is D

Explanation

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