A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure.

Exhibits

The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Administer O2 to maintain oxygen saturation greater than 90%.

Prepare the client for intubation.

Apply continuous ECG monitoring.

Obtain the client’s family history.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Rationales:

Administer O2 to maintain oxygen saturation greater than 90%: This prescription is indicated. Hypoxia can exacerbate cardiac and respiratory issues, so it is essential to maintain adequate oxygen levels in the blood. Supplemental oxygen can help improve tissue oxygenation and reduce strain on the heart.
Apply continuous ECG monitoring: This prescription is indicated. Continuous ECG monitoring is crucial in detecting arrhythmias and ischemic changes in a patient with cardiac symptoms and irregular pulse. Early detection allows for timely intervention and management of potentially life-threatening cardiac events.
Obtain the client’s family history: This prescription is nonessential. While obtaining a family history is useful for identifying potential genetic predispositions to cardiac and metabolic conditions, it is not immediately necessary for the acute management of the client’s current symptoms.
Prepare the client for intubation: This prescription is contraindicated. The client is currently maintaining an adequate respiratory rate and oxygen saturation on room air. There is no indication of respiratory failure or inability to maintain airway patency. Intubation would be an unnecessarily invasive procedure at this time.

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Correct Answer is A

Explanation

Choice A rationale

The first upward deflection in an ECG represents the P wave, indicating atrial depolarization. It precedes the QRS complex and corresponds to the electrical activity associated with atrial contraction, initiating the cardiac cycle.

Choice B rationale

The peak of the first wave corresponds to the R wave, not the P wave. The R wave is a part of the QRS complex, representing ventricular depolarization, and is not associated with atrial depolarization.

Choice C rationale

The downward deflection following the peak is the S wave, part of the QRS complex, indicating ventricular depolarization. It is not related to the P wave, which specifically represents atrial depolarization.

Choice D rationale

The second upward deflection is the T wave, which represents ventricular repolarization. It follows the QRS complex and is not associated with atrial depolarization or the P wave. .

A. 0.9% normal saline IV at 50 mL/hr continuous. B. Laboratory testing of serum potassium upon admission. C. Bumetanide 1 mg IV bolus every 12 hr. D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain.

Correct Answer is A

Explanation

Choice A rationale

Administering 0.9% normal saline IV at 50 mL/hr continuously in acute heart failure can exacerbate fluid overload, worsening symptoms like pulmonary edema.

Choice B rationale

Serum potassium testing is essential in heart failure management due to potential electrolyte imbalances from medications like diuretics.

Choice C rationale

Bumetanide, a loop diuretic, is used to manage fluid overload in acute heart failure by promoting diuresis and reducing volume overload.

Choice D rationale

Morphine sulfate can help alleviate pain and anxiety in heart failure patients, reducing oxygen demand and improving symptoms.

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A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure. Exhibits The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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