Rhythm Strip
The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but is complaining of slight nausea after eating breakfast. What is the nurse's best action?
Complete the remainder of the assessment.
Obtain an order for adenosine IV.
Notify the physician of the symptoms.
Administer the prescribed ace inhibitor.
The Correct Answer is C
A. Complete the remainder of the assessment: While ongoing assessment is important, the rhythm strip shows atrial flutter, a potentially unstable arrhythmia, and the client is experiencing symptoms (nausea after breakfast) which could suggest compromised cardiac output. Completing the remainder assessment delays the necessary intervention.
B. Obtain an order for adenosine IV: Adenosine is typically used for stable supraventricular tachycardia (SVT), not for atrial flutter, as it may not terminate the rhythm. It may slow conduction enough to better visualize flutter waves, but initiating it without a provider's order or further evaluation is inappropriate.
C. Notify the physician of the symptoms: The client’s rhythm strip shows atrial flutter with a rapid ventricular response and the patient is experiencing nausea, which could indicate decreased perfusion or early decompensation. Immediately notifying the provider is the safest and most appropriate action for further evaluation and treatment planning.
D. Administer the prescribed ACE inhibitor: ACE inhibitors are used for blood pressure control or heart failure management, not for acute rhythm disturbances. Administering it would not address the current rhythm or symptoms and could worsen hypotension if cardiac output is compromised.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer amiodarone 200 mg IV push: Amiodarone is used for shockable rhythms like ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) that are refractory to defibrillation. The rhythm on the monitor is asystole, which is non-shockable, and amiodarone is not indicated here.
B. Defibrillate the client using 200 joules: Defibrillation is only appropriate for shockable rhythms such as VF or pulseless VT. Asystole is not shockable, and defibrillation in this rhythm would be ineffective and inappropriate.
C. CPR until the physician stops the code: The rhythm strip shows asystole, a flatline with no electrical activity. The priority intervention is to initiate and continue high-quality cardiopulmonary resuscitation (CPR) immediately and continue until the code is terminated by the physician. This is consistent with Advanced Cardiac Life Support (ACLS) guidelines.
D. Administer adenosine 12 mg IV push: Adenosine is used to terminate supraventricular tachycardia (SVT) and is not indicated in asystole or during cardiac arrest. It would have no effect in a rhythm with no electrical activity.
Correct Answer is B
Explanation
A. Breast cancer treated with chemotherapy and radiation: While cancer and its treatments can suppress the immune system, they are not direct causes of infectious endocarditis. The condition is more closely related to bacteremia and structural heart damage.
B. Periodontal disease and gum surgery three months ago: Periodontal disease involves chronic bacterial infection of the gums and supporting structures of the teeth, this transient bacteremia can lead to infectious endocarditis. Oral infections and invasive dental procedures can introduce bacteria into the bloodstream, particularly streptococci, which can colonize damaged heart valves and cause infectious endocarditis.
C. Type II diabetic for ten years: Diabetes increases the risk of infection generally, but it is not a specific cause of endocarditis. Without a portal of entry or bacteremia, the condition alone is not strongly associated with endocarditis.
D. Myocardial infarction one year ago: A prior MI may result in reduced cardiac function but does not directly lead to infectious endocarditis unless it has resulted in damaged valves or introduced infection, which is not indicated here.
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