A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

Perform synchronized cardioversion.

Start cardiopulmonary resuscitation (CPR).

Apply supplemental O₂ via non-rebreather mask.

Give atropine per agency dysrhythmia protocol.

Answer and Explanation

The Correct Answer is B

The patient is apneic (not breathing) and has no palpable pulses, indicating a cardiac arrest or severe cardiovascular compromise. In this situation, the most appropriate action for the nurse to take next is to start cardiopulmonary resuscitation (CPR) immediately.

CPR is a life-saving procedure that combines chest compressions and rescue breaths to circulate oxygenated blood to vital organs when the heart is not effectively pumping. In the case of cardiac arrest, early initiation of CPR is critical to improve the chances of survival and minimize potential brain damage.

The heart monitor shows sinus tachycardia, rate 132, which suggests that the electrical impulses are reaching the heart, but the heart is not effectively pumping blood due to the lack of a palpable pulse. This condition requires immediate intervention with CPR rather than other treatments such as synchronized cardioversion (option A) or administering atropine (option D).

While applying supplemental oxygen via a non-rebreather mask (option C) is generally important in many emergency situations, it is not the immediate priority when a patient is apneic and has no palpable pulses. In such cases, CPR takes precedence to restore circulation and maintain oxygen delivery to the body's vital organs.

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Correct Answer is A

Explanation

In a client with chronic kidney disease (CKD), metabolic acidosis is a common acid-base disorder due to impaired excretion of acid and decreased bicarbonate reabsorption in the kidneys. The arterial blood gas values associated with metabolic acidosis in CKD are a low pH (acidemia), low bicarbonate (HCO3-), and normal or low partial pressure of carbon dioxide (PaCO2). Option A fits this pattern, with a pH of 7.25 (acidic), HCO3- of 19 mEq/L (low), and a PaCO2 of 30 mm Hg (within the normal to low range).

Option B shows a pH of 7.30 (acidic) but with a higher bicarbonate level of 26 mEq/L, which is not consistent with metabolic acidosis. The elevated bicarbonate level suggests metabolic alkalosis, which is not expected in a client with CKD.

Option C has a pH of 7.50 (alkaline) with an elevated bicarbonate level of 20 mEq/L and a low PaCO2 of 32 mm Hg. This set of values is indicative of metabolic alkalosis, which is not expected in a client with CKD.

Option D has a pH of 7.55 (alkaline) with an elevated bicarbonate level of 30 mEq/L and a low PaCO2 of 31 mm Hg. This set of values is indicative of metabolic alkalosis, which is not expected in a client with CKD.

A. Serum troponin B. Arterial blood gasses C. 12-lead electrocardiogram D. B-type natriuretic peptide

Correct Answer is D

Explanation

B-type natriuretic peptide (BNP) is a diagnostic blood test that can be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure.

BNP is a hormone produced by the heart in response to increased pressure and volume in the heart, especially in cases of heart failure. When the heart is under stress, such as in heart failure, it releases BNP into the bloodstream. Elevated levels of BNP are strongly indicative of heart failure, and the testis particularly helpful in differentiating heart failure from other conditions that may present withsimilar symptoms, such as pulmonary disorders.

When a patient presents with acute shortness of breath, the BNP test can provide valuable information to help guide the diagnosis and treatment. If the BNP level is elevated, it suggests that heart failure is likely the cause of the symptoms, and appropriate interventions can be initiated promptly.

While other diagnostic tests like serum troponin (A) are important for assessing heart damage in conditions like myocardial infarction (heart attack), they may not be as specific for heart failure.

Arterial blood gases (B) are helpful in evaluating gas exchange and acid-base balance, especially in patients with respiratory distress, but they are not specific for diagnosing heart failure.

A 12-lead electrocardiogram (ECG) (C) can provide valuable information about the heart's electrical activity and any signs of acute myocardial infarction or other cardiac abnormalities, but it is not the primary test for diagnosing heart failure. An ECG can support the diagnosis if specific changes suggestive of heart failure are present, but the BNP test provides more direct evidence for heart failure diagnosis.

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A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Correct Answer is A

Explanation

Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

Correct Answer is D

Explanation

After receiving change-of-shift report on a heart failure unit, which client should the nurse assess first?

While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)

The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

The nurse identifies that a patient with chronic kidney disease is at risk for which electrolyte disturbance?

A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?