A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?
Elective cardioversion
Defibrillation
CPR
Radiofrequency catheter ablation
The Correct Answer is A
The correct answer is: A. Elective cardioversion
Choice A reason:
Elective cardioversion is a medical procedure that is used to restore a normal heart rhythm in patients experiencing certain types of arrhythmias, including ventricular tachycardia (VT), when they are stable. It involves the delivery of a controlled electric shock to the heart, which is synchronized with the heart's electrical activity to convert the abnormal rhythm back to a normal sinus rhythm. This procedure is typically performed when VT is not causing hemodynamic instability and the patient is not in immediate danger.
Choice B reason:
Defibrillation is an emergency treatment for life-threatening cardiac arrhythmias, particularly ventricular fibrillation (VF) or pulseless ventricular tachycardia. It involves delivering a high-energy electric shock to the heart unsynchronized to the heart's electrical cycle, aiming to reset the heart's electrical state and allow it to reestablish an effective rhythm. In the scenario provided, where the patient is experiencing VT but not VF, defibrillation would not be the first line of action unless the VT deteriorates into VF or the patient becomes pulseless.
Choice C reason:
CPR, or cardiopulmonary resuscitation, is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. In the case of VT, if the patient is conscious and has a pulse, CPR is not indicated. CPR would only be necessary if the patient's heart stops beating (cardiac arrest) as a result of the VT.
Choice D reason:
Radiofrequency catheter ablation is a procedure used to treat some types of arrhythmias, including VT, by destroying the area of heart tissue that is causing the abnormal heart rhythm. This treatment is generally considered when medication is ineffective or not tolerated, or in recurrent VT. It is not typically the first line of treatment in an acute setting where the patient is stable and experiencing VT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason: This is correct because placing ice to the bridge of the client’s nose can cause vasoconstriction and reduce blood flow to the nasal mucosa.
Choice B Reason: This is incorrect because tilting the client's head backward can cause blood to drain into the throat and increase the risk of aspiration, nausea, and vomiting.
Choice C Reason: This is correct because moving the client into high-Fowler position can lower the blood pressure in the head and neck and decrease bleeding.
Choice D reason Reason This is incorrect because instructing the client to blow his nose can dislodge any clots that have formed and worsen bleeding.
Choice E Reason: This is correct because applying pressure to the nares can compress the bleeding site and promote clotting.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.
Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.
Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.
Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.
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