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. 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.

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?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (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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