A patient is admitted to the emergency department with chest pain and ECG findings showing ST-segment elevation.
The nurse notes oxygen saturation at 89 Which intervention should the nurse prioritize to initiate first?

Choice A rationale

Sinus bradycardia is defined by a heart rate below 60 beats per minute with a regular rhythm and discernible P waves. In this case, the client has a heart rate of 92 per minute and an irregular rhythm, which immediately rules out bradycardia. Furthermore, sinus rhythms must have identifiable P waves and measurable PR intervals, both of which are absent in this client's presentation, pointing toward a more chaotic supraventricular origin.

Choice B rationale

First-degree heart block is characterized by a consistent delay in conduction between the atria and ventricles, resulting in a PR interval greater than 0.20 seconds. However, the rhythm remains regular, and P waves must be clearly visible and associated with every QRS complex. The client in the scenario has an irregular rhythm and unidentifiable P waves, which is inconsistent with the stable, albeit delayed, conduction seen in a first-degree block.

Choice C rationale

Supraventricular tachycardia usually manifests as a very rapid, regular rhythm with rates often exceeding 150 beats per minute. While P waves may be difficult to see because they are buried in the preceding T waves, the hallmark is the absolute regularity of the R-to-R intervals. The client's rhythm is described as irregular, which is the primary clinical feature that distinguishes atrial fibrillation from the regular, rapid pacing of a supraventricular tachycardia.

Choice D rationale

Atrial fibrillation is defined by the absence of discrete P waves and an irregularly irregular ventricular rhythm. The fibrillatory waves from the atria do not produce a measurable PR interval because there is no organized atrial depolarization. The QRS duration of 0.10 seconds is within the normal range of 0.06 to 0.12 seconds, indicating that ventricular conduction is still following the normal pathways once the atrioventricular node allows an impulse through.

Choice A rationale

Teaching the patient about fluid restriction is a critical component of long-term chronic disease management for heart failure to prevent future exacerbations. However, education is a lower priority during an acute phase of fluid volume excess. When a patient presents with physical symptoms like a significant 3-pound weight gain and peripheral edema, the nurse must prioritize physiological stabilization and pharmacological intervention over teaching, as the patient may be too distressed to effectively learn or retain information.

Choice B rationale

A thorough respiratory assessment is vital to check for pulmonary edema, often manifested by crackles or decreased oxygen saturation, which frequently accompanies right-sided heart failure progression. While assessment is a key nursing step, the symptoms provided already confirm significant systemic fluid overload. After identifying the problem through these initial findings, the nurse should move to the intervention that will directly resolve the fluid excess and prevent the patient from progressing into acute respiratory distress or failure.

Choice C rationale

Encouraging sodium restriction is a necessary dietary modification because sodium promotes water retention through osmotic pressure, worsening the workload on a failing heart. Like fluid restriction education, this is a secondary prevention strategy meant for long-term maintenance. In the presence of acute jugular vein distention and rapid weight gain, dietary changes will not work fast enough to relieve the current pressure on the cardiovascular system or reduce the extracellular fluid volume effectively.

Choice D rationale

Administering a prescribed diuretic, such as furosemide, is the priority because it directly addresses the fluid volume excess by promoting the excretion of sodium and water by the kidneys. This pharmacological intervention reduces the preload and systemic venous pressure, thereby alleviating the jugular vein distention and ankle edema. Rapid diuresis is necessary to prevent the fluid from backing up further into the pulmonary circulation, which could lead to life-threatening pulmonary edema and impaired gas exchange.