A nurse is caring for a client who reports shortness of breath and heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse palpates a rapid carotid pulse with a blood pressure of 70/30, and the client reports feeling dizzy. The nurse should anticipate the need for which priority action?

Initiate external pacing.

Initiate CPR.

Defibrillation.

Synchronized cardioversion.

Answer and Explanation

The Correct Answer is D

A. External pacing is not indicated for ventricular tachycardia with a pulse. Pacing is typically used for bradyarrhythmias.
B. CPR is only necessary if the client is pulseless. Since the client has a pulse, a more appropriate intervention is needed.
C. Defibrillation is used for pulseless VT or ventricular fibrillation, but this client has a pulse and is symptomatic.
D. Synchronized cardioversion is the appropriate intervention for unstable ventricular tachycardia with a pulse. The shock is synchronized to the R wave to prevent inducing ventricular fibrillation.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Worsening of congestive heart failure is suggested by symptoms including labored breathing, coarse crackles, jugular vein distention (JVD), cool/clammy skin, and low oxygen saturation. These findings indicate pulmonary congestion due to fluid overload.
Applying O₂ at 6L/min helps improve oxygenation and alleviate respiratory distress. Lower-flow oxygen (such as 2L/min) may not be sufficient in acute heart failure exacerbation.
Monitoring respiratory rate is essential to track breathing effort and response to treatment.
Monitoring oxygen saturation helps assess oxygenation status and effectiveness of interventions.
Smoking cessation is important for long-term lung and cardiovascular health but does not address the acute issue.
WBC count and temperature are more relevant to infections like pneumonia rather than acute heart failure.

A. Increased blood pressure B. Increased hematocrit C. Increased temperature D. Increased heart rate E. Increased respiratory rate

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

Explanation

A. Increased blood pressure is expected due to excess fluid in the vascular system, which raises blood volume and pressure.
B. Hematocrit is typically decreased in fluid volume overload due to hemodilution rather than increased.
C. Increased temperature is not a common finding in fluid overload, as fever is usually associated with infection rather than volume excess.
D. Increased heart rate (tachycardia) occurs as the heart compensates for excess fluid and decreased cardiac output.
E. Increased respiratory rate is common due to pulmonary congestion and fluid accumulation in the lungs, leading to dyspnea.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is caring for a heart failure client with a history of dietary noncompliance. The nurse suspects the client has fluid volume overload. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)

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

Explanation

A nurse is reviewing the lab results and electrocardiogram (ECG) of a patient with End Stage Renal Disease (ESRD). The nurse correlates which ECG finding to a potassium level of 6.8?

A nurse is caring for a client with right-sided heart failure. Which of the following symptoms should the nurse include in teaching the client about signs of worsening heart failure? (SELECT ALL THAT APPLY)

A nurse is reviewing cardiac rhythms and heart blocks for a critical care course. The nurse is aware that which of the following describes first-degree heart block?

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following medications should the nurse hold the morning of the stress test?

A nurse is caring for a client who is having an acute myocardial infarction (MI). The nurse is aware that which of the following are part of the assessment of cardiac pain? (SELECT ALL THAT APPLY).

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

A nurse is teaching a newly licensed nurse about evaluating cardiac rhythms. Which of the following best explains calculation of the heart rate?