Rhythm Strip
The nurse is evaluating the following rhythm strip on a client in the telemetry unit. The client is alert and oriented but is complaining of slight nausea after eating breakfast. What is the nurse's best action?
Complete the remainder of the assessment.
Obtain an order for adenosine IV.
Notify the physician of the symptoms.
Administer the prescribed ace inhibitor.
The Correct Answer is C
A. Complete the remainder of the assessment: While ongoing assessment is important, the rhythm strip shows atrial flutter, a potentially unstable arrhythmia, and the client is experiencing symptoms (nausea after breakfast) which could suggest compromised cardiac output. Completing the remainder assessment delays the necessary intervention.
B. Obtain an order for adenosine IV: Adenosine is typically used for stable supraventricular tachycardia (SVT), not for atrial flutter, as it may not terminate the rhythm. It may slow conduction enough to better visualize flutter waves, but initiating it without a provider's order or further evaluation is inappropriate.
C. Notify the physician of the symptoms: The client’s rhythm strip shows atrial flutter with a rapid ventricular response and the patient is experiencing nausea, which could indicate decreased perfusion or early decompensation. Immediately notifying the provider is the safest and most appropriate action for further evaluation and treatment planning.
D. Administer the prescribed ACE inhibitor: ACE inhibitors are used for blood pressure control or heart failure management, not for acute rhythm disturbances. Administering it would not address the current rhythm or symptoms and could worsen hypotension if cardiac output is compromised.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Convert milligrams to micrograms.
1 mg = 1000 mcg.
0.05 mg × 1000 mcg/mg = 50 mcg
Desired dose = 25 mcg
Available dose = 50 mcg/tablet
Calculate the number of tablets.
Number of tablets = Desired dose / Available dose per tablet
= 25 mcg / 50 mcg/tablet
= 0.5
The nurse should administer 0.5 tablet.
Correct Answer is C
Explanation
A. Increase in systolic blood pressure 10 mmHg above client's norm: A mild increase in systolic blood pressure is not a specific indicator of mitral stenosis progression. Blood pressure fluctuations may occur due to various factors and are not typically used as a primary marker of worsening valve disease.
B. reports dyspnea after walking up 2 flights of stairs: Exertional dyspnea is a common early symptom of mitral stenosis due to reduced left atrial emptying and pulmonary congestion. However, this does not necessarily indicate worsening unless the symptom becomes more severe or occurs with minimal exertion.
C. Jugular vein distention and +3 peripheral edema: These are signs of right-sided heart failure, which may result from long-standing mitral stenosis leading to pulmonary hypertension and subsequent right ventricular hypertrophy and failure. This indicates disease progression and worsening cardiac function.
D. Complaints of epigastric pain after eating a large meal: Epigastric discomfort is not a typical symptom of mitral stenosis and is more likely related to gastrointestinal issues. It does not reflect the status or progression of the cardiac condition.
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