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 A
Explanation
A. Ensure all tubing connections are tightened: Tight tubing connections are critical in preventing accidental disconnection, which can result in rapid blood loss and air embolism. Arterial lines are under high pressure, so securing all connections is a top priority to ensure patient safety and maintain line integrity.
B. Apply a pressure dressing to the insertion site: A transparent occlusive dressing not a pressure dressing is used for arterial lines to allow for site visualization and reduce the risk of infection. A pressure dressing could obscure signs of bleeding or compromise the catheter’s position.
C. Perform an Allen's test: Allen’s test is performed prior to radial arterial line insertion to assess collateral circulation via the ulnar artery for preventing ischemic complications if the radial artery is compromised. Performing the test afterward does not prevent complications and is no longer relevant once the catheter is placed.
D. Obtain a portable x-ray to confirm placement: X-rays are used to confirm the placement of central lines, not peripheral arterial lines like the radial line. Arterial line placement is confirmed by waveform analysis and blood return, not imaging.
Correct Answer is D
Explanation
A. Blood pressure reading of 120/80: While a normal blood pressure is desirable, this value alone does not indicate improvement in fluid overload or pulmonary symptoms. It may remain normal even if respiratory status worsens or fails to improve.
B. Urine output 30 mL for one hour: Although urine output is an important measure of diuretic effectiveness, 30 mL/hr is the minimum acceptable rate, not necessarily a strong indicator of clinical improvement. More robust diuresis may be expected following IV furosemide.
C. Serum sodium level is 135 mEq/L (135–145): A normal sodium level reflects stable electrolyte status but does not directly indicate improvement in pulmonary congestion or dyspnea. Sodium may be affected by many factors unrelated to heart failure symptom relief.
D. Respiratory rate 16 per minute: A decrease in respiratory rate from 26 to 16 suggests improved oxygenation, reduced pulmonary congestion, and decreased work of breathing. It is the most direct and clinically relevant indicator of symptomatic improvement in this context.
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