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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because a decreased level of consciousness is a late sign of shock, not an early one. Decreased level of consciousness indicates that the brain is not receiving enough oxygen and blood ﬂow, which can lead to irreversible damage and death.

Choice B Reason: This is correct because increased respiratory rate is an early sign of shock, indicating hypoxia. This finding indicates that the client is experiencing hypoxia, which is a lack of oxygen in the tissues and organs. Hypoxia is a common and early sign of shock, which is a condition where the body's vital organs do not receive enough blood

ﬂow and oxygen due to low blood pressure, low cardiac output, or low blood volume. The client's respiratory rate increases as a compensatory mechanism to increase oxygen intake and delivery.

Choice C Reason: This is incorrect because hypotension is a late sign of shock, not an early one. Hypotension indicates that the blood pressure is too low to maintain adequate perfusion and oxygenation to the vital organs.

Choice D Reason: This is incorrect because anuria is a late sign of shock, not an early one. Anuria indicates that the kidneys are not receiving enough blood ﬂow and oxygen, which can result in acute kidney injury or failure.

A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. Laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. Bumetanide 1 mg IV bolus every 12 hr

Correct Answer is C

Explanation

Choice a) is incorrect because morphine sulfate is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that can relieve pain, anxiety, and dyspnea. Morphine sulfate can also reduce the preload and afterload of the heart, which can improve the cardiac output and oxygenation.

Choice b) is incorrect because laboratory testing of serum potassium is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that is important for the normal function of the cardiac cells and muscles. Serum potassium can be altered by various factors, such as renal function, acid-base balance, medications, or dietary intake. Serum potassium can aﬀect the cardiac rhythm and contractility, which can inﬂuence the outcome of the client.

Choice c) is correct because 0.9% normal saline IV at 50 mL/hr continuous is a prescription that requires clarification for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that can maintain the ﬂuid balance and blood pressure in the body. However, 0.9% normal saline can also cause ﬂuid overload and worsen the heart failure symptoms, such as edema, crackles, and dyspnea. The nurse should clarify with the provider if this prescription is appropriate for the client's condition and if there are any parameters or limits for the ﬂuid administration.

Choice d) is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that can increase the urine output and reduce the ﬂuid volume and pressure in the body. Bumetanide can also decrease the preload and afterload of the heart, which can improve the cardiac output and oxygenation.

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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?

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