Complete the following sentence from the list of options
Monitor
The nurse is caring for a client who is admitted to the telemetry unit with a new onset of the following rhythm. The nurse assesses the rhythm as
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D","dropdown-group-3":"D"}
Atrial fibrillation: This is a common arrhythmia where the atria quiver instead of contracting normally, leading to irregular heart rhythms.
Amiodarone- an antiarrhythmic medication may be used to control the heart rate or rhythm in atrial fibrillation.
Heparin-an anticoagulant prevent thromboembolic events, such as stroke, anticoagulants like heparin, enoxaparin, or newer agents like rivaroxaban are used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B. Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C. A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D. Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.
Correct Answer is D
Explanation
A. The 20-gauge catheter in the right wrist is not ideal for blood transfusions, as wrist veins are smaller and may be less optimal for high-flow transfusions.
B. An 18-gauge catheter is appropriate for blood transfusions, but the catheter is currently in use for potassium chloride, which would need to be discontinued. The best choice is a separate site.
C. A 22-gauge catheter is not large enough for blood transfusion; it may cause hemolysis or slow the transfusion rate.
D. The 20-gauge catheter in the right forearm is an appropriate size for a blood transfusion and is currently infusing normal saline, which does not interfere with the blood transfusion.
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