A patient is having frequent premature ventricular contractions.
The nurse would place priority on assessment of which information?
Causative factors, such as caffeine
Sensation of fluttering or palpitations
Blood pressure and Oxygen saturation
Precipitation factors, such as infection .
The Correct Answer is C
Choice A rationale:
While it's important to assess for potential causative factors of premature ventricular contractions (PVCs), such as caffeine intake, it's not the immediate priority in this scenario.
The nurse's primary focus should be on assessing the patient's hemodynamic stability and oxygenation status, as frequent PVCs can compromise cardiac function and lead to serious complications.
Assessment of causative factors can be done subsequently, once the patient's immediate physiological needs have been addressed.
Choice B rationale:
The patient's subjective experience of palpitations or fluttering is valuable information, but it doesn't provide objective data about their cardiovascular status.
The nurse needs to prioritize objective assessment of vital signs, such as blood pressure and oxygen saturation, to evaluate the patient's hemodynamic stability and oxygenation.
Subjective symptoms can be further explored after obtaining objective data.
Choice D rationale:
Precipitating factors, such as infection, can contribute to PVCs, but they are not the immediate priority in this case.
The nurse's focus should be on assessing the patient's current cardiovascular status and ensuring their stability.
Investigation of potential precipitating factors can be done later, as part of a comprehensive assessment and management plan.
Choice C rationale:
Blood pressure and oxygen saturation are the most crucial parameters to assess in a patient with frequent PVCs.
Here's why:
Blood pressure: PVCs can disrupt the normal rhythm of the heart, potentially leading to a decrease in cardiac output and hypotension.
Hypotension can compromise perfusion to vital organs, such as the brain and kidneys, and can be a sign of hemodynamic instability.
Therefore, it's essential to monitor the patient's blood pressure closely.
Oxygen saturation: PVCs can also impair the heart's ability to pump blood effectively, which can lead to decreased oxygen delivery to the tissues.
This can result in hypoxemia, which can further worsen cardiac function and cause other complications.
Monitoring oxygen saturation using pulse oximetry is crucial to ensure adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Atrial fibrillation (AF) is characterized by the absence of P waves on the ECG, the presence of fibrillatory waves, and an irregularly irregular rhythm. This is due to chaotic electrical activity in the atria, which results in disorganized atrial contractions. The fibrillatory waves, which are often described as "f" waves or "sawtooth" waves, represent the rapid and irregular electrical activity in the atria. They are typically best seen in lead II, V1, or V2 of the ECG.
Here is a more detailed explanation of the key features of AF that support this answer:
Absence of P waves: In normal sinus rhythm, the P wave represents the electrical impulse that originates in the sinoatrial (SA) node and depolarizes the atria. In AF, the SA node is no longer in control of the atrial rhythm, and there is no organized atrial depolarization. As a result, P waves are absent on the ECG.
Presence of fibrillatory waves: The fibrillatory waves seen in AF represent the disorganized electrical activity in the atria. They are typically irregular in amplitude and frequency, and they can vary in appearance from patient to patient.
Irregularly irregular rhythm: The ventricular rhythm in AF is also irregular because the impulses from the atria are not conducted to the ventricles in a regular pattern. This results in an irregularly irregular rhythm, which is a hallmark feature of AF.
Key points to remember:
AF is the most common type of cardiac arrhythmia.
It can be asymptomatic or cause a variety of symptoms, including palpitations, shortness of breath, fatigue, and lightheadedness.
AF is a risk factor for stroke and heart failure.
Treatment for AF may include medications to control heart rate or rhythm, blood thinners to reduce the risk of stroke, and in some cases, procedures to restore normal heart rhythm.
Correct Answer is A
Explanation
The correct answer is A. Electrocardiogram.
Choice A rationale:
Electrocardiogram (ECG) is the priority diagnostic procedure for a suspected myocardial infarction (MI) due to several compelling reasons:
Rapidity: An ECG can be performed quickly and easily at the bedside, providing immediate results within minutes. This swiftness is crucial in the context of MI, where time is of the essence to initiate appropriate treatment and salvage viable heart tissue.
Sensitivity: The ECG is highly sensitive in detecting the electrical changes that occur during an MI. It can identify characteristic ST-segment elevation or depression, T wave inversions, and other abnormalities that strongly suggest myocardial ischemia or infarction.
Specificity: While not perfectly specific for MI, the ECG can often distinguish it from other conditions that may cause chest pain, such as pericarditis or pulmonary embolism. This diagnostic differentiation is crucial for guiding appropriate management.
Non-invasiveness: The ECG is a non-invasive procedure that does not involve any needles, catheters, or exposure to radiation. This makes it a safe and readily accessible test, even for patients who may be hemodynamically unstable or have other medical conditions.
Cost-effectiveness: The ECG is a relatively inexpensive diagnostic tool compared to other imaging modalities like echocardiography or cardiac angiography. This cost-effectiveness makes it a valuable first-line test in evaluating potential MI, allowing for efficient resource allocation.
Rationales for other choices:
Choice B (Papercut): This is not a relevant diagnostic procedure for MI and is therefore incorrect.
Choice C (Cardiac Angiogram): While cardiac angiography can definitively visualize coronary artery blockages, it is an invasive procedure that carries risks and requires specialized facilities and personnel. It is typically reserved for cases where the diagnosis remains uncertain after non-invasive testing or when intervention is planned.
Choice D (Echocardiogram): Echocardiography can assess heart function and detect structural abnormalities, but it is less sensitive than ECG for the early electrical changes of MI. It may be used as an adjunct test to provide additional information, but it is not the priority procedure in the initial evaluation.
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