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 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.

Correct Answer is ["10"]

Explanation

Determine the heparin concentration:
- You have 25,000 units of heparin in 250 mL of normal saline.
- Concentration = 25,000 units / 250 mL = 100 units/mL
Calculate the mL/hr rate:
- The order is for 1,000 units/hour.
- Drip rate (mL/hr) = 1,000 units/hour / 100 units/mL = 10 mL/hour

Answer = 10mL/hr

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A Nurse is preparing to start a heparin drip on a client with acute coronary syndrome. Ordered: Give Heparin 1000 units per hour, standard dilution of 25,000 units in 250 mL of normal saline. What is the correct drip setting for the pump in mL/hr?

Correct Answer is ["10"]

Explanation

A nurse is caring for a client with an acute myocardial infarction (AMI). The nurse is preparing medications for the client and recognizes that which medication will dilate the client’s coronary blood vessels?

A nurse is caring for a client diagnosed with infective endocarditis. The nurse is aware that which of the following is the priority assessment finding for this patient?

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 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?

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A nurse is providing care and education to a client after an acute myocardial infarction. Which of the following statements should the nurse make regarding cardiac enzyme studies?