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The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.)

Provide continued sedation.

Remove crash cart from the room.

Assess the chest for burns.

Ensure electrodes are in place for continued monitoring.

Document results of the procedure.

Answer and Explanation

Correct Answer : C,D,E

Choice A Reason:

Provide continued sedation.

Providing continued sedation is not typically necessary after a cardioversion. The sedation used during the procedure is usually short-acting, and the client should begin to wake up shortly after the procedure is completed. Continuous sedation is not required unless there are specific medical reasons, which should be determined by the healthcare provider.

Choice B Reason:

Remove crash cart from the room.

The crash cart should remain in the room until the client is fully stable. Removing it immediately after the procedure is not advisable because the client may still be at risk for complications such as arrhythmias or other cardiac events. Keeping the crash cart nearby ensures that emergency equipment is readily available if needed.

Choice C Reason:

Assess the chest for burns.

Assessing the chest for burns is an important nursing action following a cardioversion. The electrical shock delivered during the procedure can cause burns on the skin where the electrodes were placed. It is essential to check for any signs of burns or skin irritation and provide appropriate care if needed.

Choice D Reason:

Ensure electrodes are in place for continued monitoring.

Ensuring that the electrodes are in place for continued monitoring is crucial. Continuous cardiac monitoring is necessary to observe the client’s heart rhythm and detect any potential complications or recurrence of arrhythmias. Proper placement and function of the electrodes are essential for accurate monitoring.

Choice E Reason:

Document results of the procedure.

Documenting the results of the procedure is a critical nursing action. Accurate documentation includes noting the client’s response to the cardioversion, any complications, and the current heart rhythm. This information is vital for ongoing care and communication with the healthcare team.

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Correct Answer is ["A","D","E"]

Explanation

Choice A Reason:

Cool, clammy skin is a common symptom in patients with atrial fibrillation, especially when the heart rate is very high. This symptom occurs due to decreased cardiac output, which leads to poor perfusion of the skin. When the heart is beating too fast, it doesn’t have enough time to fill properly, resulting in less blood being pumped out to the body. This can cause the skin to feel cool and clammy as the body tries to compensate for the reduced blood flow.

Choice B Reason:

Respiratory rate of 20 is within the normal range for adults, which is typically 12-20 breaths per minute. While it is important to monitor respiratory rate in patients with atrial fibrillation, a rate of 20 does not indicate any immediate distress or abnormality. Therefore, this choice is not particularly relevant to the assessment of a patient with a heart rate of 143 beats/min due to atrial fibrillation.

Choice C Reason:

Flushing of the skin is not a typical symptom associated with atrial fibrillation. Flushing can occur due to various reasons such as fever, anxiety, or certain medications, but it is not directly linked to the high heart rate or the irregular rhythm seen in atrial fibrillation. Therefore, this choice is not applicable in this context.

Choice D Reason:

Hypotension (low blood pressure) is a significant concern in patients with atrial fibrillation, especially when the heart rate is very high. The rapid heart rate can lead to decreased cardiac output, as the heart does not have enough time to fill properly between beats. This can result in lower blood pressure, which can cause symptoms such as dizziness, fainting, and fatigue. Monitoring blood pressure is crucial in managing patients with atrial fibrillation to prevent complications.

Choice E Reason:

Chest discomfort is a common symptom in patients with atrial fibrillation, particularly when the heart rate is very high. The irregular and rapid heart rate can cause the heart to work harder, leading to increased oxygen demand and potentially reduced oxygen supply to the heart muscle. This imbalance can result in chest pain or discomfort, which is a warning sign that the heart is under stress. It is important to assess and address chest discomfort promptly to prevent further cardiac complications.

A. Increase in the temperature from 37.5°C (99.5°F) to 38.6°C (101.5°F) B. Decrease in the urinary output from 50 to 30 mL per hour C. Increase in the heart rate from 88 to 110/min D. Decrease in the respiratory rate from 20 to 16/min

Correct Answer is B

Explanation

Choice A reason: An increase in temperature is not a primary indicator of hypovolemic shock. While fever can occur due to infection or inflammation, it is not directly related to hypovolemic shock, which is primarily characterized by a significant loss of blood or fluids leading to decreased perfusion and oxygenation of tissues.

Choice B reason: A decrease in urinary output is a critical sign of hypovolemic shock. When the body loses a significant amount of blood or fluids, the kidneys receive less blood flow, leading to reduced urine production. This is a compensatory mechanism to conserve fluids and maintain blood pressure. Normal urine output is typically around 30 to 50 mL per hour, so a drop below this range is concerning.

Choice C reason: An increase in heart rate is a common response to hypovolemic shock as the body attempts to maintain cardiac output and blood pressure despite the loss of blood volume. Tachycardia (increased heart rate) is one of the early signs of shock, indicating that the heart is working harder to pump blood to vital organs.

Choice D reason: A decrease in respiratory rate is not typical of hypovolemic shock. In fact, hypovolemic shock often leads to an increased respiratory rate (tachypnea) as the body tries to compensate for decreased oxygen delivery to tissues. A decrease in respiratory rate could indicate other issues but is not a hallmark of hypovolemic shock.

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The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a heart rate of 143 beats/min with atrial fibrillation. Which assessment data will the nurse anticipate? Select all that apply:

Correct Answer is ["A","D","E"]

Explanation

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Correct Answer is B

Explanation

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