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
Sexual activity uses about as much energy as climbing two flights of stairs. This comparison can help patients understand that if they can perform activities of similar exertion without chest pain or undue fatigue, it may be safe to resume sexual activity. However, patients should always consult with their healthcare provider before resuming sexual activity after an acute myocardial infarction (AMI).
Choice B rationale
While holding and cuddling are good ways to maintain intimacy after a heart attack, this does not directly address the patient’s question about safely resuming sexual intercourse.
Choice C rationale
While it is true that the doctor will provide sexual guidelines when the patient’s heart is strong enough, this response does not provide the patient with immediate guidance or reassurance.
Choice D rationale
While most patients are able to enjoy intercourse without any complications, this statement may be too general and does not take into account the individual patient’s health status and recovery progress.

A. A 39-year-old patient who has right calf tenderness and swelling after a plane ride B. A 58-year-old patient taking anticoagulants for atrial fibrillation who has black stools C. A 67-year-old patient who has a gangrenous foot ulcer with a weak pedal pulse D. A 50-year-old patient who is reporting sudden sharp and severe upper back pain .

Correct Answer is D

Explanation

Choice A rationale
While calf tenderness and swelling after a plane ride could potentially indicate a deep vein thrombosis, this condition is not immediately life-threatening in most cases. The patient would need evaluation and treatment, but other patients might have more urgent needs14.
Choice B rationale
A patient taking anticoagulants for atrial fibrillation who has black stools could potentially have gastrointestinal bleeding, which would need evaluation. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice C rationale
A patient with a gangrenous foot ulcer and a weak pedal pulse would need evaluation and treatment. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice D rationale
A patient reporting sudden sharp and severe upper back pain could potentially have an aortic dissection, which is a life-threatening condition that requires immediate evaluation and treatment. Therefore, this patient should be assessed first14.

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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

For a patient recovering from an acute myocardial infarction (AMI) who inquires about safely resuming sexual intercourse, what would be the best response from the nurse?

Correct Answer is A

Explanation

After receiving a change-of-shift report, which patient admitted to the emergency department should the nurse assess first?

Correct Answer is D

Explanation

The nurse is caring for a client with an acute myocardial infarction (AMI). What emergent procedure does the nurse anticipate the physician will order?

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?

If a patient diagnosed with hypertension is prescribed Propranolol (Inderal), what patient history should prompt the nurse to consult with the healthcare provider before administering this drug?

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

A nurse is caring for a patient who has undergone an angiogram. What should the nurse prioritize in assessing and documenting for this patient?

What is the primary cause of myocardial ischemia?

Coarctation of the aorta refers to the local narrowing of the aorta near which location?

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?