The nurse is caring for a client with sinus bradycardia at a rate of 32 beats/min, blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which is the appropriate action?
Give the scheduled dose of diltiazem (Cardizem).
Reposition the patient on the left side.
Have the patient perform the Valsalva maneuver.
Apply the transcutaneous pacemaker (TCP) pads
The Correct Answer is D
Sinus bradycardia with a heart rate of 32 beats/min and accompanying hypotension and symptoms of feeling faint indicates significant hemodynamic compromise. In such cases, the first-line intervention is to provide external cardiac pacing through transcutaneous pacemaker (TCP) pads. TCP can help increase the heart rate and improve cardiac output by delivering electrical impulses to the heart.
Administering the scheduled dose of diltiazem (Cardizem), a calcium channel blocker, is not appropriate in this situation. Diltiazem can further lower the heart rate and blood pressure, exacerbating the client's symptoms and potentially leading to adverse effects.
Repositioning the patient on the left side or having the patient perform the Valsalva maneuver are not effective interventions for treating sinus bradycardia with hemodynamic compromise. These actions may be used in specific situations, but in this case, the client requires immediate intervention to address the low heart rate and blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The most appropriate intervention for a client diagnosed with peripheral arterial insufficiency is: Encourage the client to engage in a moderate amount of exercise. Peripheral arterial insufficiency is a condition characterized by reduced blood flow to the extremities, typically the legs, due to narrowed or blocked arteries. Regular exercise is an important component of managing peripheral arterial insufficiency. Exercise helps improve circulation, promote collateral blood vessel development, and increase the distance a client can walk before experiencing pain (intermittent claudication). Therefore, encouraging the client to engage in a moderate amount of exercise, such as walking, under healthcare provider guidance is crucial.]
The other options are not appropriate interventions for peripheral arterial insufficiency:
Elevating the legs and arms above the heart when resting: While elevation can be beneficial for certain conditions, such as reducing swelling in venous insufficiency, it is not the primary intervention for peripheral arterial insufficiency. Elevation alone does not improve arterial blood flow and may not effectively address the underlying circulatory issues.
Encouraging extended periods of sitting or standing: Prolonged sitting or standing can further restrict blood flow and exacerbate symptoms in clients with peripheral arterial insufficiency. Encouraging regular movement and avoiding prolonged immobility is important to maintain adequate circulation.
Discouraging walking in order to limit pain: While walking may cause pain or discomfort in clients with peripheral arterial insufficiency (intermittent claudication), it is important to encourage walking as part of an exercise regimen. Walking helps improve symptoms over time and promotes overall cardiovascular health.
Correct Answer is D
Explanation
Monitoring a client after a transesophageal echocardiogram involves observing the client for any immediate post-procedure complications or adverse reactions. This may include assessing vital signs, monitoring for signs of bleeding or infection, and reporting any concerning symptoms or changes in the client's condition to the nurse.
Checking the client's catheter site after a coronary angiogram requires assessing the site for bleeding, hematoma, or signs of infection. This task involves more complex assessment skills and would typically be performed by the nurse.
Teaching a patient about exercise electrocardiography involves providing education on the purpose of the test, the procedure itself, and any preparation or precautions the patient needs to take. This task requires specialized knowledge and is best performed by the nurse who can address the patient's specific questions and concerns.
Attaching ECG monitoring electrodes after a patient bathes requires technical knowledge and skill in properly placing the electrodes and ensuring accurate ECG readings. This task also falls within the scope of the nurse's responsibilities.
Delegation should be based on the UAP's skill set, training, and the complexity of the task. While the UAP can provide valuable support in monitoring a client after a transesophageal echocardiogram, the other tasks mentioned require the expertise and knowledge of a nurse.
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