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. Taking a diuretic before bed can lead to nocturia and disrupt sleep. It is usually recommended to take it in the morning.
B. Daily weight tracking helps detect fluid retention, a key indicator of worsening heart failure. A weight gain of 2 lbs in 24 hours or 5 lbs in a week should be reported to the provider.
C. NSAIDs (e.g., naproxen) should be avoided as they can cause fluid retention and worsen heart failure.
D. Sodium intake should be limited to 2 grams (2000 mg) per day, not 4 grams, to help prevent fluid overload.

A. Suggest that the client use a salt substitute. B. Obtain a blood sample for a serum sodium level. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a 12-lead ECG.

Correct Answer is D

Explanation

A. Salt substitutes often contain potassium and should be avoided in hyperkalemia.
B. While assessing other electrolytes may be useful, the immediate concern is evaluating the effects of hyperkalemia on cardiac function.
C. Citrus fruits and bananas are high in potassium and should be avoided when potassium levels are elevated.
D. A 12-lead ECG is essential to assess for cardiac dysrhythmias, as hyperkalemia can cause life-threatening arrhythmias such as peaked T waves and widened QRS complexes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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