Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best?
Stop and ventilate the patient with 100% oxygen.
Check the patient's potassium level
Give prescribed PRN antidysrhythmic medications.
Decrease the suction pressure to 80 mm Hg.
The Correct Answer is A
Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.
B. Check the patient's potassium level in (option B) is incorrect because While electrolyte imbalances, including low potassium levels (hypokalemia), can contribute to cardiac dysrhythmias, checking the potassium level is not the immediate priority when PVCs occur during suctioning.
C. Give prescribed PRN antidysrhythmic medications in (option C) is incorrect because: Administering antidysrhythmic medications without further assessment or evaluation may not be appropriate in this situation.
D. Decrease the suction pressure to 80 mm Hg in (option D) is incorrect because: While adjusting suction pressure may help prevent further irritation, it is not the initial priority when PVCs are present during suctioning.
E. Documenting the dysrhythmia in the patient's chart in (option E) is incorrect because: Documentation is important but should not be the initial action when a patient experiences PVCs during suctioning. Patient safety and immediate intervention take precedence.
Therefore, when PVCs occur during suctioning, the nurse should stop the procedure, provide ventilatory support with 100% oxygen, and assess the patient's response to intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Mean arterial pressure (MAP) is a measure of the average pressure within the arteries during one cardiac cycle. It represents the perfusion pressure that drives blood flow to organs and tissues. MAP is calculated using the formula:
MAP = Diastolic blood pressure + 1/3 (Systolic blood pressure - Diastolic blood pressure)
Blood loss, particularly in cases of significant hemorrhage, leads to a decrease in blood volume. When blood volume decreases, there is less circulating blood available to generate pressure within the arterial system. This reduction in blood volume results in decreased MAP.
Therefore, in the case of massive blood loss after trauma, the student can correlate it with a lower blood volume, which in turn leads to a lower MAP. The decrease in blood volume reduces the perfusion pressure, compromising organ and tissue perfusion
A. It causes vasoconstriction and increased MAP in (option A) is incorrect because: While vasoconstriction can occur as a compensatory mechanism to maintain blood pressure, it does not necessarily lead to an increased MAP in the context of significant blood loss.
C. It raises cardiac output and MAP in (option C) is incorrect because Blood loss typically leads to a reduction in cardiac output due to decreased blood volume. Therefore, it does not raise cardiac output and MAP.
D. There is no direct correlation to MAP in (option D) is incorrect because: There is indeed a direct correlation between blood loss and MAP. As blood volume decreases, MAP decreases as well.
Therefore, the correct correlation between blood loss and MAP is that lower blood volume lowers MAP.
Correct Answer is A
Explanation
The characteristics described in the monitor strip analysis suggest ventricular tachycardia. The absence of a visible P wave and the wide and distorted QRS complex indicates that the electrical impulse is originating in the ventricles rather than the atria. The ventricular rate of 196 and regular R-R intervals further support the diagnosis of ventricular tachycardia.
B. Atrial fibrillation in (option B) is incorrect because it is characterized by irregularly irregular R-R intervals and the absence of discernible P waves. The QRS complex is typically narrow
C. Atrial tachycardia in (option C) is incorrect because it would have a rapid atrial rate with regular R-R intervals, and P waves may or may not be discernible. The QRS complex is typically narrow.
D. Ventricular fibrillation in (option D) is incorrect because it would present as a chaotic, rapid, and irregular electrical activity with no discernible P waves, QRS complexes, or regular R-R intervals. It is a life-threatening emergency that requires immediate defibrillation.
Therefore, based on the provided information, the nurse would interpret the patient's cardiac rhythm as ventricular tachycardia. However, it is important to note that an accurate interpretation should be made by a qualified healthcare professional, and the patient's clinical context should also be considered.
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