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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While fasting may be required before certain procedures, it is not the most crucial piece of information that the nurse needs to relay to the healthcare provider prior to a cardiac catheterization and coronary angiogram.
Choice B rationale
A shellfish allergy is crucial information because the dye used in an angiogram can cause an allergic reaction in people who are allergic to shellfish.
Choice C rationale
Although a previous heart attack is significant medical history, it is not the most crucial piece of information to relay prior to this procedure.
Choice D rationale
The rating of the patient’s pedal pulses is not the most crucial piece of information to relay prior to this procedure.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Promoting a diet high in saturated fats is not a recommended strategy for preventing cardiovascular disease. Saturated fats can raise the level of cholesterol in your blood and increase your risk of heart disease and stroke.
Choice B rationale
Advising smoking cessation is a crucial intervention in preventing cardiovascular disease. Chemicals in tobacco can damage the heart and blood vessels, leading to narrowing of the arteries (atherosclerosis). Atherosclerosis can ultimately lead to a heart attack.
Choice C rationale
Regular blood pressure monitoring is important because high blood pressure is a significant risk factor for heart disease. It can cause the arteries that supply blood to your heart muscle to harden and narrow, leading to a heart attack.
Choice D rationale
Regular cholesterol screenings are essential because high levels of cholesterol can lead to the buildup of plaques in your arteries, increasing your risk of heart disease.
Choice E rationale
Encouraging regular physical exercise is a key strategy in preventing cardiovascular disease. Regular exercise helps control your weight and reduce your chances of developing other conditions that may put a strain on your heart, such as high blood pressure, high cholesterol, and diabetes.
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