A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

What is the first action the nurse should take?

Begin cardiopulmonary resuscitation (CPR).

Cardiovert the client with a biphasic defibrillator.

Assess airway, breathing, and circulation.

Administer an amiodarone bolus followed by a drip.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice B rationale
Cardioverting the client with a biphasic defibrillator is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice C rationale
The first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern is to assess the patient’s airway, breathing, and circulation.
Choice D rationale
Administering an amiodarone bolus followed by a drip is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

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Correct Answer is A

Explanation

Choice A rationale
Vasotec, an Angiotensin-Converting Enzyme (ACE) inhibitor, is commonly used to treat conditions like high blood pressure and heart failure. It works by relaxing blood vessels, which allows blood to flow more easily and reduces blood pressure.
Choice B rationale
Decreased urine output is not a typical outcome of taking Vasotec. In fact, ACE inhibitors like Vasotec can sometimes increase urine output by improving kidney function.
Choice C rationale
Increased appetite is not a known effect of Vasotec. If a patient experiences a significant change in appetite while taking this medication, they should consult their healthcare provider.
Choice D rationale
Increased fluid retention is not a typical outcome of taking Vasotec. ACE inhibitors like Vasotec are often used to help reduce fluid retention in patients with conditions like heart failure.

A. Elevate the leg above the level of the heart. B. Assist the patient in gently exercising the leg. C. Apply a compression stocking to the leg. D. Keep the patient in bed in the supine position.

Correct Answer is D

Explanation

Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.

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A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. What is the first action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What positive outcome should a nurse anticipate in a patient taking Vasotec, an Angiotensin-Converting Enzyme (ACE) inhibitor?

Correct Answer is A

Explanation

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg, consistent with acute arterial occlusion. After the nurse notifies the healthcare provider, what should the nurse do next?

Correct Answer is D

Explanation

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A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

What is the first action the nurse should take?