A nurse is caring for a client who is in pulseless ventricular tachycardia (V-Tach). The nurse recognizes the need for which priority intervention?
Synchronized Cardioversion
Repeat electrocardiogram (ECG)
Assessment of blood pressure
Immediate Defibrillation
The Correct Answer is D
Rationale:
A. Synchronized cardioversion is not appropriate for pulseless ventricular tachycardia.
B. A repeat ECG is not necessary for pulseless ventricular tachycardia.
C. Assessment of blood pressure is not the priority in pulseless ventricular tachycardia.
D. Immediate defibrillation is the priority in pulseless ventricular tachycardia to restore a perfusing rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Salt substitutes often contain potassium and should be avoided in clients with hyperkalemia.
B. Citrus juices and bananas are high in potassium and should be avoided in clients with hyperkalemia.
C. A 12-lead ECG may include changes such as peaked T wave, flattened P wave, prolonged PR interval, ST depression, and prolonged QRS duration.
D. A serum sodium level should be obtained but it is not the priority in this case.
Correct Answer is A
Explanation
Rationale:
A. Petechiae are small, pinpoint red or purple spots on the skin that may indicate bleeding or thrombocytopenia, which can be a side effect of heparin therapy.
B. Slowing pulse rate is not typically associated with heparin therapy.
C. Confusion is not typically associated with heparin therapy.
D. Pruritus (itching) is not typically associated with heparin therapy.
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