A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?

Start CPR

Prepare for radiofrequency catheter ablation

Prepare for defibrillation

Prepare for cardioversion

Answer and Explanation

The Correct Answer is D

A. Start CPR: CPR is indicated if the client is unresponsive and pulseless, which is not the case here as the client is alert.

B. Prepare for radiofrequency catheter ablation: This is a long-term treatment for recurrent VT but not appropriate for acute management.

C. Prepare for defibrillation: Defibrillation is used for pulseless VT or ventricular fibrillation, not for a stable VT with a pulse.

D. Prepare for cardioversion: Synchronized cardioversion is the appropriate intervention for a stable VT with a pulse to restore normal rhythm.

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Correct Answer is D

Explanation

A. “There is some swelling in your right leg that is making you feel this way.” Swelling would typically cause discomfort or pressure, but it would not be responsible for the sensation of pain in the amputated limb.

B. "Your brain is responding to being inactive from the surgery." This answer does not address the real cause of the pain, which is related to the brain's continued perception of the missing limb.

C. "Don't worry about your right foot. The pain will go away within a few days." Phantom limb pain is a common phenomenon after amputation and may persist long-term. Dismissing it is not appropriate.

D. "Your brain is still receiving impulses about your right foot." This is an accurate explanation for phantom limb pain. After amputation, the brain may still interpret sensations from the absent limb, causing pain or discomfort in the "missing" foot.

A. Pelvic fracture B. Femoral neck fracture C. Tibia fracture D. Fibula fracture

Correct Answer is B

Explanation

A. Pelvic fracture: Pelvic fractures may cause significant pain and instability but do not typically result in a shortened, adducted, and externally rotated leg.

B. Femoral neck fracture: These findings (shortened, adducted, externally rotated leg) are classic for a femoral neck fracture due to muscle contraction and displacement of the bone.

C. Tibia fracture: Tibia fractures typically present with swelling and deformity, not shortening or rotation of the leg.

D. Fibula fracture: A fibula fracture alone rarely causes leg shortening or rotation as it is a non-weight-bearing bone.

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A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

Correct Answer is D

Explanation

The nurse is assessing a client and find their right leg is shortened, adducted and externally rotated. These assessment findings would indicate which type of injury?

Correct Answer is B

Explanation

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