A nurse is caring for a client who is in pulseless ventricular tachycardia (V-Tach). The nurse recognizes the need for which priority intervention?

Immediate Defibrillation

Synchronized Cardioversion

Perform CPR

Repeat electrocardiogram (ECG)

Answer and Explanation

The Correct Answer is A

A. Defibrillation is the priority intervention for pulseless ventricular tachycardia, as it can restore a normal rhythm. It should be performed as soon as possible.
B. Synchronized cardioversion is used for hemodynamically unstable tachyarrhythmias with a pulse, not for pulseless V-Tach.
C. CPR should be initiated if a defibrillator is not immediately available, but defibrillation is the definitive treatment.
D. Repeating an ECG does not address the immediate life-threatening situation.

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Correct Answer is B

Explanation

A. A blood pressure of 110/70 and heart rate of 90 is within normal limits and does not indicate an immediate complication.
B. Swelling at the insertion site and a cool extremity suggest arterial occlusion or hematoma formation, which is a serious complication requiring immediate intervention. This may indicate impaired blood flow to the limb.
C. Oozing blood from the site may require monitoring and pressure application but is not as concerning as signs of arterial compromise.
D. Not voiding post-procedure can be due to bedrest or IV contrast, but it is not an urgent concern.

A. Assess for acute pain B. Monitor fluid volume excess C. Prevention of falls D. Monitor heart rate and rhythm E. Assess for neurologic changes

Correct Answer is ["C","D","E"]

Explanation

A. Assessing for acute pain is unnecessary. Sinus bradycardia is not typically associated with acute pain unless another condition, such as myocardial infarction, is present.
B. Monitoring fluid volume excess is incorrect. Sinus bradycardia is not directly related to fluid overload; however, fluid status may need to be monitored in clients with underlying cardiac conditions.
C. Prevention of falls is correct. Bradycardia can lead to dizziness, hypotension, and syncope, increasing the risk of falls.
D. Monitoring heart rate and rhythm is correct. Continuous monitoring is essential to detect any worsening bradycardia or associated arrhythmias.
E. Assessing for neurologic changes is correct. Bradycardia can reduce cerebral perfusion, leading to symptoms such as confusion, dizziness, or syncope.

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A nurse is caring for a client who is in pulseless ventricular tachycardia (V-Tach). The nurse recognizes the need for which priority intervention?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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