Rhythm Strip
A client comes to the emergency department (ED) complaining of a "racing heart and nervousness." The client's blood pressure is 106/60. The cardiac monitor displays the rhythm below. Which nursing action should be performed first?
Prepare the client for electrical cardioversion
Perform a carotid massage on the client.
Administer lidocaine 1mg/hour.
Ask the client if they drank a caffeinated beverage
The Correct Answer is B
A. Prepare the client for electrical cardioversion: Electrical cardioversion is reserved for unstable patients (e.g., hypotension, altered mental status, chest pain, or signs of shock). This client, while tachycardic, has a blood pressure of 106/60, which indicates relative stability. Cardioversion is not the first-line intervention in stable supraventricular tachycardia (SVT).
B. Perform a carotid massage on the client: Carotid sinus massage is a vagal maneuver used to slow conduction through the AV node and can terminate paroxysmal supraventricular tachycardia (PSVT). It is a non-invasive, first-line intervention for a stable patient with narrow-complex tachycardia, as shown on the ECG strip.
C. Administer lidocaine 1 mg/hour: Lidocaine is an antiarrhythmic used primarily to treat ventricular arrhythmias, such as ventricular tachycardia or fibrillation. It is not indicated for atrial or supraventricular tachycardias and would not address the underlying rhythm.
D. Ask the client if they drank a caffeinated beverage: While excessive caffeine intake can contribute to tachycardia, asking about caffeine use does not address the acute arrhythmia or guide immediate treatment. It may be part of history-taking but is not a priority intervention in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Calculate the total volume to be infused in drops.
Total drops = Total volume (mL) × Drop factor (gtts/mL)
= 1000 mL × 60 gtts/mL
= 60000 gtts
Calculate the total infusion time in minutes.
Total infusion time (minutes) = Total hours × 60 minutes/hour
= 8 hours × 60 minutes/hour
= 480 minutes
Calculate the IV flow rate in drops per minute (gtts/min).
IV rate (gtts/min) = Total drops / Total infusion time (minutes)
= 60000 gtts / 480 minutes
= 125
=125 gtts/min
Correct Answer is D
Explanation
A. "The diaphragmatic nerve overdrives the rapid rhythm:" The phrenic (diaphragmatic) nerve controls the diaphragm for breathing and plays no role in cardiac rhythm regulation. It is unrelated to the autonomic control of heart rate or supraventricular tachycardia (SVT) management.
B. "Vagal stimulation decreases peripheral vascular resistance:" Vagal stimulation primarily affects the heart by decreasing the rate and conduction through the AV node. Its effect on vascular resistance is minimal, making this explanation inaccurate in the context of SVT treatment.
C. "The vagus nerve increases the heart rate, overdriving the rhythm:" The vagus nerve has a parasympathetic effect, slowing down the heart rate, not increasing it. Overdrive pacing is a different concept and not related to vagal maneuvers like carotid massage.
D. "The vagus nerve slows the heart rate": The carotid sinuses in the neck contain baroreceptors that are sensitive to pressure. Massaging these sinuses stimulates the vagus nerve to release acetylcholine, which in turn slows conduction through the AV node and may terminate episodes of SVT. This response demonstrates an accurate understanding of the purpose of the procedure.
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