Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who reports shortness of breath and heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse notes a carotid pulse with a BP of 70 systolic, the client reports feeling dizzy. The nurse should anticipate the need for which priority action?
A. Radiofrequency catheter ablation
Radiofrequency catheter ablation is a long-term treatment for recurrent VT, not an immediate intervention.
B. CPR
CPR is indicated for pulseless VT, but this client has a carotid pulse.
C. Defibrillation
Defibrillation is used for pulseless VT or ventricular fibrillation, but this client is still perfusing.
D. Synchronized cardioversion
Synchronized cardioversion is the appropriate treatment for unstable VT with a pulse, as it delivers a timed shock to restore normal rhythm.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Nsg 232 Proctored Exam Med Surg. Take the full exam now
Full Explanation
A. Radiofrequency catheter ablation is a long-term treatment for recurrent VT, not an immediate intervention.
B. CPR is indicated for pulseless VT, but this client has a carotid pulse.
C. Defibrillation is used for pulseless VT or ventricular fibrillation, but this client is still perfusing.
D. Synchronized cardioversion is the appropriate treatment for unstable VT with a pulse, as it delivers a timed shock to restore normal rhythm.
Similar Questions
A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following medications should the nurse hold the morning of the stress test?
A. Tenormin (Atenolol)
Tenormin (Atenolol) is a beta-blocker that reduces the heart rate and may affect the results of the stress test. Therefore, it should be held the morning of the test.
B. Heparin
Heparin is an anticoagulant and is not typically held before a stress test.
C. Keflex (Cephalexin)
Keflex (Cephalexin) is an antibiotic and is not typically held before a stress test.
D. Hold all medications
Holding all medications is not necessary for a stress test, but specific medications that may interfere with the test, such as beta-blockers, should be held.
Full Explanation
Rationale:
A. Tenormin (Atenolol) is a beta-blocker that reduces the heart rate and may affect the results of the stress test. Therefore, it should be held the morning of the test.
B. Heparin is an anticoagulant and is not typically held before a stress test.
C. Keflex (Cephalexin) is an antibiotic and is not typically held before a stress test.
D. Holding all medications is not necessary for a stress test, but specific medications that may interfere with the test, such as beta-blockers, should be held.
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?
A. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week.
A weight gain of 0.5 kg (1 lb) in a week is not typically concerning for heart failure exacerbation.
B. It is okay to skip a dose of diuretic.
Skipping a dose of a diuretic can lead to fluid retention and exacerbate heart failure symptoms.
C. Check weight daily when it is easiest.
Weighing daily is important for monitoring fluid retention, but the specific time of day is not as crucial as consistent timing.
D. Call the provider if you gain 2 lbs. in 24 hours
A weight gain of 2 lbs. in 24 hours can indicate fluid retention and worsening heart failure.
Full Explanation
Rationale:
A. A weight gain of 0.5 kg (1 lb) in a week is not typically concerning for heart failure exacerbation.
B. Skipping a dose of a diuretic can lead to fluid retention and exacerbate heart failure symptoms.
C. Weighing daily is important for monitoring fluid retention, but the specific time of day is not as crucial as consistent timing.
D. A weight gain of 2 lbs. in 24 hours can indicate fluid retention and worsening heart failure.
A client has undergone diagnostic testing and received a diagnosis of sinus bradycardia. Which interventions are most appropriate and should be included in the client's plan of care? (SELECT ALL THAT APPLY)
A. Prevention of vagal stimulation
Preventing vagal stimulation can help prevent bradycardia.
B. Assess for acute pain
Acute pain is not typically associated with sinus bradycardia.
C. Prevention of falls
Preventing falls is important because bradycardia can lead to dizziness and falls.
D. Assess for neurologic changes
Assessing for neurologic changes is important because bradycardia can affect cerebral perfusion.
E. Monitor fluid volume excess
Monitoring fluid volume excess is not directly related to sinus bradycardia.
Full Explanation
Rationale:
A. Preventing vagal stimulation can help prevent bradycardia.
B. Acute pain is not typically associated with sinus bradycardia.
C. Preventing falls is important because bradycardia can lead to dizziness and falls.
D. Assessing for neurologic changes is important because bradycardia can affect cerebral perfusion.
E. Monitoring fluid volume excess is not directly related to sinus bradycardia.