A patient on the telemetry unit develops atrial flutter with a heart rate of 150, respirations 26, b/p 118/64 and a o2 saturation of 90% while sitting down. Which action should the nurse do FIRST?
Prepare to administer Atropine
Reassess the patient's blood pressure
Prepare to administer Adenosine IV push
Prepare to administer supplemental 02 via nasal cannula.
The Correct Answer is D
The correct answer is choice D: Prepare to administer supplemental O2 via nasal cannula.
Choice A rationale:
Atropine is used to treat bradycardia (slow heart rate), not atrial flutter with a rapid heart rate. Administering Atropine in this scenario could potentially worsen the patient’s condition by increasing the heart rate further.
Choice B rationale:
While reassessing the patient’s blood pressure is important, it is not the most immediate action. The patient’s current blood pressure is stable (118/64), and the priority is addressing the low oxygen saturation and high respiratory rate, which indicates respiratory distress.
Choice C rationale:
Adenosine is used to treat certain types of supraventricular tachycardia by temporarily slowing the heart rate, but it is not the first-line treatment for atrial flutter. Additionally, the patient’s blood pressure is stable, and there is no indication of hemodynamic instability that would necessitate immediate rate control.
Choice D rationale:
The patient’s oxygen saturation is 90%, which is below the normal range, and they are tachypneic with a respiratory rate of 26 breaths per minute. The first action should be to administer supplemental oxygen to improve oxygenation and prevent hypoxemia-related complications. Oxygen therapy can help stabilize the patient’s condition and improve oxygen saturation levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: A client newly diagnosed with myocardial infarction would require a nurse with more experience due to the complexity and potential instability of the condition678910.
Choice B rationale: A client complaining of crushing chest pain could be experiencing a serious condition such as a myocardial infarction. This client would require a nurse with more experience678910.
Choice C rationale: A client scheduled for a cardiac catheterization and requires patient teaching would be an appropriate assignment for a new graduate nurse. This client is stable and the task of patient teaching is within the scope of a new graduate678910.
Choice D rationale: A client admitted with unstable angina would require a nurse with more experience due to the potential for rapid changes in the client’s condition678910.
So, the correct answer is C, after analysing all choices.
Correct Answer is C
Explanation
Choice A rationale: Prolonged PR intervals are not typically associated with the use of polystyrene sulfonate2.
Choice B rationale: Widening of the QRS complex is not typically seen with the use of polystyrene sulfonate2.
Choice C rationale: Polystyrene sulfonate is used to treat hyperkalemia (high potassium levels). As potassium levels decrease, the peaked T wave seen in hyperkalemia may reduce234.
Choice D rationale: An increase in T wave amplitude is not typically associated with the use of polystyrene sulfonate2.
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