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 B

Explanation

Resumption of sexual activity after a myocardial infarction (MI) is an important topic to address as part of the overall recovery and rehabilitation process. It should be discussed along with other physical activities during the patient's recovery. The nurse should initiate the discussion in a supportive and non-judgmental manner, addressing the patient's concerns, fears, and questions about sexual activity after an MI.

Sexual activity is a normal part of life, and patients may have concerns about the safety and appropriateness of engaging in sexual activity after a significant cardiac event like an MI. Discussing it along with other physical activities helps normalize the topic and allows the nurse to provide accurate information, address any misconceptions, and offer guidance on when and how to resume sexual activity safely. Patients should be encouraged to have an open dialogue with their healthcare provider about their concerns and any specific questions they may have related to resuming sexual activity.

A. Diuretics B. Narcotics C. Vasodilators D. Positive inotropes

Correct Answer is A

Explanation

Diuretics are the primary class of drugs used to treat volume overload in patients with acute decompensated heart failure (ADHF). These medications help to increase urine output, reducing the overall fluid volume in the body and relieving congestion in the lungs and other tissues.

The goal of using diuretics in ADHF is to alleviate symptoms such as shortness of breath, edema (swelling), and fluid retention by promoting the elimination of excess fluid. The most commonly used diuretics in this setting are loop diuretics (e.g., furosemide, bumetanide), which have a potent diuretic effect and can rapidly reduce fluid overload.

While narcotics, vasodilators, and positive inotropes may have roles in specific cases of ADHF, they are not the primary drugs used to treat volume overload. Narcotics may be used for pain management, vasodilators to reduce afterload (the resistance the heart has to pump against), and positive inotropes to increase the heart's contractility in certain situations. However, the first-line treatment for volume overload in ADHF is diuretic therapy.

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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

The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). How should resumption of sexual activity be discussed?

Correct Answer is B

Explanation

The nurse recalls that which type of drug therapy is used to treat volume overload in patients with acute decompensated heart failure (ADHF)?

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?

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