A patient who is complaining of a racing heart and nervousness comes to the emergency department.
The patient's blood pressure is 102/68. The nurse places the patient on a cardiac monitor and obtains an ECG tracing. Which action should the nurse take next?

Choice A rationale

The sinoatrial node is the primary pacemaker of the heart, but in atrial fibrillation, the electrical impulses are chaotic and originate from multiple ectopic foci within the atria. Decreasing sinoatrial node conduction would not address the rapid ventricular response seen in this patient, whose rate is 166 bpm. The goal is to slow the conduction through the atrioventricular node to protect the ventricles from the rapid atrial rate, rather than focusing on the sinoatrial node.

Choice B rationale

While maintaining anticoagulation with heparin is crucial in atrial fibrillation to prevent thromboembolic events such as a stroke, it is not the immediate main goal in the acute phase of a rapid ventricular response. Blood stasis in the atria increases the risk of clot formation, but the rapid heart rate of 166 bpm significantly reduces diastolic filling time and cardiac output. Anticoagulation addresses long term complications, whereas rate control addresses the immediate hemodynamic stability.

Choice C rationale

The patient's respiratory rate is 20 breaths per minute, which is the upper limit of the normal range of 12 to 20 breaths per minute. The lungs are clear and chest expansion is normal, suggesting that primary oxygenation is currently adequate. While supplemental oxygen may be used, it does not treat the underlying tachycardia. Improving oxygenation is secondary to resolving the rapid heart rate that is causing the potential for hemodynamic instability and decreased myocardial perfusion.

Choice D rationale

The main goal in managing acute atrial fibrillation with a rapid ventricular response is rate control. A heart rate of 166 bpm significantly shortens diastole, reducing the time available for the ventricles to fill and for the coronary arteries to be perfused. This can lead to decreased cardiac output and heart failure. Administering Cardizem, a calcium channel blocker, helps slow the conduction through the atrioventricular node, thereby reducing the ventricular rate to a safer level.

Choice A rationale

Discussing sensitive hospital data or potential public health threats with family members violates patient confidentiality and professional boundaries. Family members do not have the expertise or authority to manage a potential chemical warfare scenario or a public health crisis. Such discussions could lead to unnecessary panic within the community without addressing the underlying clinical issue. Professional concerns must always be directed through the established institutional hierarchy to ensure a coordinated and legal response.

Choice B rationale

Reporting unusual patterns of illness to a supervisor is the first step in the chain of command for disaster management. The supervisor can validate the findings across different shifts and departments to determine if a formal alert is necessary. In the context of potential chemical exposure or biological threats, early reporting is essential for initiating decontamination protocols and notifying public health authorities. This action ensures that the hospital can mobilize resources and protect both staff and the public.

Choice C rationale

While the Centers for Disease Control and Prevention must eventually be notified of a potential mass casualty or chemical event, the individual nurse should follow the facility's internal notification policy first. Jumping directly to federal agencies can bypass local emergency management protocols and delay the immediate hospital-level response. The hospital administration and infection control departments are responsible for official communications with state and federal health agencies. Reporting to the supervisor ensures the information follows the correct legal channels.

Choice D rationale

Ignoring a significant increase in specific, severe symptoms like pulmonary edema and shortness of breath is a failure of clinical judgment and professional duty. Pulmonary edema involves fluid accumulation in the alveoli, which is a medical emergency and not a typical presentation of uncomplicated influenza. Nurses must remain vigilant for clusters of symptoms that suggest environmental or intentional harm. Dismissing these signs delays life-saving interventions and prevents the identification of a potentially larger public health catastrophe.