Kaplan NCLEX Practice Question of the Day

The nurse provides care for a client diagnosed with a myocardial infarction 12 hours ago. The client is on bed rest and has oxygen by nasal cannula at 2 L per minute. The nurse notes the sudden onset of this cardiac rhythm:

Which action does the nurse take first?

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Increase nasal cannula flow to 4 L/min.
The client is experiencing premature ventricular contractions (PVCs) with an underlying normal sinus rhythm. There is no indication that the client is hypoxic.
Obtain an oxygen saturation level.
The client is experiencing PVCs, which are common post-myocardial infarction and may indicate underlying perfusion or electrolyte issues. There is no indication that the client is hypoxic.
Notify the health care provider. (Correct Answer)
The client is at high risk for ventricular tachycardia or fibrillation. Dysrhythmias are the leading cause of death immediately post-myocardial infarction. Pharmacologic intervention is needed. The nurse should contact the health care provider to obtain prescriptions.
Obtain a 12-lead electrocardiogram.
A 12-lead ECG will not provide any additional information. The nurse already knows that the client is showing signs of ventricular irritability.

Decision Tree:

This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.

This is a Priority Question.

Priority questions use words such as most, best, first, immediate, etc.

STEP 1: Can you identify the topic of the question?

Priority action, ventricular dysrhythmia.

STEP 2: Are the answer choices assessment or implementation?

Assessment vs. Implementation

Increase nasal cannula flow to 4 L/min. Implementation
Obtain an oxygen saturation level. Assessment
Notify the health care provider. Implementation
Obtain a 12-lead electrocardiogram. Assessment

When there is a mix of assessment and implementation answers, ask if further assessment or validation is needed. Is assessment or assessment validation needed? No, further assessment is not needed. This is an emergency situation that requires action. Eliminate #2 and 4. Move to Step 3.

STEP 3: Apply Maslow: Are the answer choices physical or psychosocial?

Maslow

Client who delivered a 9 lb, 8 oz (4.3 kg) newborn. Physical
Increase nasal cannula flow to 4 L/min. Physical
Notify the health care provider. Physical

Because a mix of physical and psychosocial answer choices does not exist, answer choices cannot be eliminated at this step. Move to Step 4.

STEP 4:Are the answer choices related to ABCs?

ABCs

1. Increase nasal cannula flow to 4 L/min. Breathing

3. Notify the health care provider. N/A

When there is a mix of ABC and non-ABC answer choices, the ABC answer choices take priority if they make sense to the topic of the question. The breathing answer does not make sense with the circulation topic. Eliminate #1. Move to Step 5.

STEP 5: What is the outcome of each of the remaining answer choices?

Evaluate the outcome(s)

3. Notify the health care provider. Yes, this client needs medications like lidocaine to stop the dysrhythmia before it progresses to ventricular fibrillation.

Select the best choice

Is #3 the correct answer? Yes, the health care provider needs to be notified immediately to prescribe medications to stop the dysrhythmia.

Does #3 make sense? Yes, the client will receive immediate care and be kept safe.

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