420 exam 1 passpoint practice
A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor exhibits the following. Which interventions would the nurse do first? You Selected:
Assess the client's airway, breathing, and circulation Rationale: The rhythm the client is experiencing is ventricular tachycardia (VT). Although all of the options listed are appropriate for someone with stable VT, it is not yet known whether the client's VT is stable, unstable, or pulseless. Therefore, the nurse must first assess the airway, breathing, circulation, and level of consciousness to establish the client's stability. Different actions are required if the client's VT is unstable or pulseless.
When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, which is the expected outcome of the drug?
Dissolve clots Rationale: Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.
A client is receiving cilostazol for peripheral artery disease causing intermittent claudication. Which statement by the client indicates to the nurse that this medication is effective?
I am able to walk further without leg pain." Rationale: Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider (HCP) . Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body.
A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign?
blood pressure Rationale: Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the health care provider (HCP) and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse?
immediate defibrillation Rationale: When ventricular fibrillation is verified, the first intervention is defibrillation. It is the only intervention that will terminate this lethal dysrhythmia. Digoxin will not help in this situation. An I.V. line will need to be established, but it is not the priority. A pacemaker may be needed, but not until the client is stabilized.
