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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While potassium is typically diluted in IV fluids, the concentration and infusion rate must be clarified before administration. A standard dilution is 10 mEq in 100 mL or 40 mEq in 1L, but this must be verified.
B. Calling the physician for clarification is the safest step. IV potassium should never be given undiluted or as an IV push due to the risk of fatal cardiac arrhythmias.
C. IV push potassium is never appropriate as it can cause cardiac arrest.
D. Administering the undiluted 20 mEq/mL solution is dangerous and requires proper dilution before administration.
Correct Answer is ["B","C","D"]
Explanation
A. A high-calcium diet does not contribute to DVT development. DVT risk factors are related to venous stasis, hypercoagulability, and endothelial damage.
B. Prolonged bed rest leads to venous stasis, increasing the risk of clot formation.
C. Post-operative clients are at higher risk for DVT due to immobility and surgical trauma, which can activate clotting mechanisms.
D. Oral contraceptive use increases the risk of DVT due to hormonal effects that promote clot formation.
E. A low BMI is not a risk factor for DVT. In contrast, obesity is a recognized risk factor due to increased venous pressure and inflammation.
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