The nurse is caring for a patient who is day 2 post-operative following a coronary artery bypass surgery (CABG). The nurse observes the following rhythm on the monitor (see image below or in the attachment of a 6-second rhythm strip). During the assessment, the nurse determines that the RR is 22, BP 82/59, Temp 102.6 F, and the patient reports chest pain 9/10. What action should the nurse take at this time?

Administer 0.4 mg nitroglycerin sublingual

Prepare for cardioversion

Prepare for defibrillation

Give acetaminophen 975 mg PO

Answer and Explanation

The Correct Answer is B

A. Administer 0.4 mg nitroglycerin sublingual: Nitroglycerin may reduce chest pain related to ischemia by decreasing preload and myocardial oxygen demand. However, this patient is hypotensive (BP 82/59), and nitroglycerin would further lower blood pressure, worsening perfusion and potentially precipitating cardiovascular collapse.

B. Prepare for cardioversion: The patient is in ventricular tachycardia with a pulse and is hemodynamically unstable, as evidenced by hypotension and severe chest pain. According to ACLS guidelines, unstable VT with a pulse requires immediate synchronized cardioversion to restore organized ventricular contraction and improve cardiac output.

C. Prepare for defibrillation: Defibrillation is indicated for pulseless ventricular tachycardia or ventricular fibrillation. Since this patient still has a pulse, synchronized cardioversion—not unsynchronized defibrillation—is the appropriate intervention to avoid inducing ventricular fibrillation.

D. Give acetaminophen 975 mg PO: Although the patient has a fever, treating hyperthermia does not address the immediate life-threatening arrhythmia and hemodynamic instability. Stabilization of the ventricular tachycardia takes priority over antipyretic administration.

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Correct Answer is C

Explanation

A. Hemoglobin 20 g/dL (reference range 13.5-18 g/dL): Elevated hemoglobin indicates hemoconcentration or polycythemia but does not directly influence heparin dosing. While high hemoglobin may affect blood viscosity, it is not a parameter used to titrate anticoagulation therapy.

B. Prothrombin time (PT) 10 seconds (reference range 12-15 seconds): PT evaluates the extrinsic coagulation pathway and is primarily used to monitor warfarin therapy, not IV heparin. A PT of 10 seconds is slightly below normal, but it does not indicate the need to adjust heparin infusion rates.

C. Activated Partial thromboplastin time (aPTT) 89 seconds (reference range 52.5-87.5 seconds): The aPTT measures the intrinsic and common coagulation pathways and is the standard parameter for titrating IV heparin. An aPTT above the therapeutic range indicates an increased risk of bleeding, requiring the nurse to decrease the heparin infusion.

D. Platelets 455,000/mm3 (reference range 150,000-400,000/mm3): Elevated platelet count (thrombocytosis) does not necessitate adjustment of heparin dosing. Heparin-induced thrombocytopenia would warrant monitoring, but in this case, platelets are elevated rather than decreased, so no immediate titration is indicated.

A. Assess the patient's blood pressure B. Set the machine to synchronize on the R wave C. Set the pacer to 60 beats per minute D. Deliver an unsynchronized defibrillation shock

Correct Answer is D

Explanation

A. Assess the patient's blood pressure: While vital signs are important, during a code blue with ventricular fibrillation (VF), the patient is pulseless and unresponsive, making immediate assessment of blood pressure unnecessary. The priority is to restore a perfusing rhythm as quickly as possible.

B. Set the machine to synchronize on the R wave: Synchronization is used for cardioversion of unstable but perfusing rhythms, such as atrial fibrillation or ventricular tachycardia with a pulse. In VF, the patient has no organized QRS complexes, so synchronization is not possible and would delay life-saving defibrillation.

C. Set the pacer to 60 beats per minute: Pacing is indicated for bradyarrhythmias, not for VF. Ventricular fibrillation requires immediate defibrillation, as pacing cannot generate organized ventricular contractions in a chaotic rhythm.

D. Deliver an unsynchronized defibrillation shock: Ventricular fibrillation is a pulseless, life-threatening arrhythmia that requires immediate unsynchronized defibrillation. Delivering the shock as soon as possible maximizes the likelihood of achieving return of spontaneous circulation and is the first-line intervention according to ACLS guidelines.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a male patient diagnosed with a Pulmonary Embolism (PE) who has been receiving a heparin IV infusion for 12 hours. Which of the following labs would require the nurse to titrate the heparin drip down?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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