A nurse is working on telemetry unit when an alarm sounds on the cardiac monitor The rhythm below is noted. What should the nurse do?

Call the physician

Administer oxygen

Initiate cardiopulmonary resuscitation (CPR)

Give a dose of epinephrine

Answer and Explanation

The Correct Answer is C

A. Call the physician: While notifying the physician is important, it is not the immediate priority in a life-threatening situation like ventricular fibrillation.

B. Administer oxygen: Administering oxygen is helpful, but the immediate priority in ventricular fibrillation is to initiate life-saving measures.

C. Initiate cardiopulmonary resuscitation (CPR): Ventricular fibrillation is a life-threatening emergency, and initiating CPR immediately is crucial to restore circulation and improve chances of survival.

D. Give a dose of epinephrine: Epinephrine is part of the advanced cardiac life support (ACLS) protocol, but it should be administered after initiating CPR and defibrillation.

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Correct Answer is A

Explanation

A. Remind the client to look for food on the left side of the tray: Homonymous hemianopsia is a condition in which a person loses vision in the same half of the visual field of each eye (in this case, the left visual field due to right-sided brain damage). The nurse should remind the client to look for food on the left side of the tray to help compensate for the visual deficit.

B. Provide a non-skid mat to alleviate plate movement. While a non-skid mat can help with plate stability, it does not address the visual field loss caused by homonymous hemianopsia.

C. Encourage the client to use his right hand when feeding himself. There is no specific benefit to using the right hand when a client is experiencing a visual deficit in the left visual field. Instead, compensating for the visual field loss is the priority.

D. Encourage the use of the wide grip utensils. Wide grip utensils are helpful for clients with limited hand mobility but will not address the specific visual impairment caused by homonymous hemianopsia.

A. Propranolol B. Procainamide C. Aspirin D. Warfarin

Correct Answer is D

Explanation

A. Propranolol: This is a beta-blocker, which may be used to control heart rate, but it does not address the risk of thromboembolism in atrial fibrillation.

B. Procainamide: This is an antiarrhythmic used for rhythm control, but it does not address stroke prevention in atrial fibrillation.

C. Aspirin: Although aspirin is sometimes used for stroke prevention, it is generally less effective than anticoagulation therapy in clients with higher CHA2DS2-VASC scores.

D. Warfarin: A CHA2DS2-VASC score of 2 indicates a moderate risk for stroke, and warfarin (or another anticoagulant) is indicated to reduce the risk of thromboembolic events.

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A nurse is working on telemetry unit when an alarm sounds on the cardiac monitor The rhythm below is noted. What should the nurse do?

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Naxlex Comprehensive Predictor Exams

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