A nurse performs an admission assessment on a 75-year-old client ...

[vicky]

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94 on 2 liters per nasal cannula.
 
  The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below:
 
  Which action should the nurse take first?
  a.
  Begin external temporary pacing.
  b.
  Assess peripheral pulse strength.
  c.
  Ask the client what medications he or she takes.
  d.
  Administer 1 mg of atropine.

Question 2

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below:
 
  Which action should the nurse take first?
  a.
  Assess airway, breathing, and level of consciousness.
  b.
  Administer an amiodarone bolus followed by a drip.
  c.
  Cardiovert the client with a biphasic defibrillator.
  d.
  Begin cardiopulmonary resuscitation (CPR).

[Brenm]

Answer to Question 1

ANS: C
This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first.

Answer to Question 2

ANS: A
Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

[vicky]

TYSM

[parker125]

Excellent