The nurse is responsible for the care of four patients.
Which patient should the nurse assess first?
A patient with sinus bradycardia, heart rate of 48, awaiting pacemaker placement.
A patient admitted 1 hour ago with new onset Atrial Fibrillation who is receiving diltiazem.
A patient admitted one day ago with thrombophlebitis who is receiving IV heparin.
A patient with end-stage, right-sided heart failure with blood pressure of 78/50 who is on hospice care
The Correct Answer is A
Choice A rationale:
Sinus bradycardia with a heart rate of 48 is a potentially life-threatening condition that requires immediate assessment and intervention. The heart rate is significantly below the normal range of 60-100 beats per minute, which means that the heart is not pumping enough blood to meet the body's needs. This can lead to symptoms such as dizziness, lightheadedness, fatigue, shortness of breath, chest pain, and even syncope (fainting). In severe cases, it can progress to cardiac arrest and death.
The patient is awaiting pacemaker placement, indicating that the bradycardia is severe and not responding to other treatment measures. This further underscores the urgency of assessment and intervention.
The nurse needs to assess the patient immediately for signs of hemodynamic instability, such as hypotension, altered mental status, and decreased urine output. The nurse should also obtain a 12-lead ECG to confirm the diagnosis of sinus bradycardia and to rule out other potential causes of the bradycardia, such as AV block or medication effects.
Prompt intervention is crucial to prevent further deterioration of the patient's condition and to avoid potentially lifethreatening complications.
Choice B rationale:
Atrial fibrillation is a common heart rhythm disorder that is characterized by rapid and irregular beating of the heart's upper chambers (atria). It can cause symptoms such as palpitations, shortness of breath, fatigue, and lightheadedness.
Diltiazem is a calcium channel blocker that is often used to control the heart rate in patients with atrial fibrillation. While it is important to monitor patients who are newly started on diltiazem for potential side effects, such as hypotension and bradycardia, it is not as urgent as assessing a patient with severe sinus bradycardia.
Choice C rationale:
Thrombophlebitis is an inflammation of a vein that is often caused by a blood clot. It can cause pain, redness, swelling, and warmth in the affected area.
IV heparin is an anticoagulant medication that is used to prevent blood clots from forming or getting larger. While it is important to monitor patients who are receiving IV heparin for potential side effects, such as bleeding, it is not as urgent as assessing a patient with severe sinus bradycardia.
Choice D rationale:
End-stage, right-sided heart failure is a serious condition that is characterized by the inability of the heart to pump blood effectively from the right ventricle to the lungs. It can cause symptoms such as shortness of breath, fatigue, edema, and abdominal swelling.
Hospice care is a type of care that focuses on providing comfort and quality of life for patients who are nearing the end of life. While it is important to provide supportive care for patients who are on hospice care, it is not as urgent as assessing a patient with severe sinus bradycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Sinus tachycardia is a heart rhythm characterized by a rate greater than 100 beats per minute, with normal P waves preceding each QRS complex.
It can be caused by various factors, including exercise, stress, fever, dehydration, medications, and medical conditions such as anemia, hyperthyroidism, and heart failure.
In the given rhythm, the rate is within the normal range (60-100 beats per minute), and the P waves are not clearly visible, making sinus tachycardia unlikely.
Choice B rationale:
Atrial flutter is a type of supraventricular tachycardia characterized by a rapid, regular atrial rate of around 250-350 beats per minute, with a characteristic "sawtooth" pattern on the ECG.
It is typically caused by a re-entry circuit within the atria, often involving the cavo-tricuspid isthmus.
The ventricular rate is usually slower than the atrial rate due to the atrioventricular (AV) node's inability to conduct all atrial impulses.
Atrial flutter can cause symptoms such as palpitations, shortness of breath, lightheadedness, and fatigue.
It can also lead to complications such as stroke and heart failure.
The given rhythm shows a regular atrial rate with a sawtooth pattern, consistent with atrial flutter.
Choice C rationale:
Atrial fibrillation is another type of supraventricular tachycardia characterized by rapid, irregular atrial activity with no discernible P waves on the ECG.
It is also caused by disorganized electrical activity in the atria.
The ventricular rate in atrial fibrillation is also irregular, and the rhythm is often described as "irregularly irregular." The given rhythm shows a regular atrial rate, making atrial fibrillation unlikely.
Choice D rationale:
Normal sinus rhythm is the heart's natural rhythm, characterized by a rate of 60-100 beats per minute, with normal P waves preceding each QRS complex.
The given rhythm does not have normal P waves, making normal sinus rhythm unlikely.
Correct Answer is D
Explanation
Choice A rationale:
Assessing lung sounds is important for evaluating respiratory status, but it is not the priority assessment before administering digoxin. Digoxin does not have a direct effect on the respiratory system, and changes in lung sounds would not necessarily indicate a contraindication to its administration.
However, in patients with heart failure, which is a common indication for digoxin, auscultating lung sounds can provide valuable information about fluid status and the effectiveness of treatment. Therefore, while not the priority assessment, lung auscultation remains a relevant part of the overall assessment of a patient receiving digoxin.
Choice B rationale:
Assessing systolic blood pressure is important for monitoring hemodynamic status, but it is not the most critical assessment before administering digoxin. Digoxin does not directly affect blood pressure, and changes in blood pressure would not necessarily indicate a contraindication to its administration.
However, in patients with hypertension, which can be a factor in heart failure, monitoring blood pressure is essential for managing overall cardiovascular health. Therefore, while not the priority assessment, blood pressure measurement remains an important aspect of care for patients receiving digoxin.
Choice C rationale:
Assessing the brachial pulse for 30 seconds can provide a general assessment of heart rate and rhythm, but it is not as accurate as assessing the apical pulse for a full minute.
The apical pulse is the most reliable way to assess heart rate and rhythm, especially in patients with irregular heartbeats or those taking medications that can affect heart rate, such as digoxin.
Therefore, assessing the apical pulse for a full minute is essential to ensure accurate assessment of the patient's cardiac status before administering digoxin.
Choice D rationale:
Assessing the apical pulse for 60 seconds is the priority assessment before administering digoxin. This is because digoxin is a cardiac glycoside that affects the heart's electrical conduction system and can slow the heart rate. It is essential to assess the patient's heart rate and rhythm before administering digoxin to ensure that it is safe to do so.
A slow heart rate (bradycardia), irregular heart rhythms (such as atrial fibrillation), or certain heart block conditions can be contraindications to digoxin administration or require dosage adjustments.
By accurately assessing the apical pulse for a full minute, the nurse can identify any potential contraindications or concerns and ensure the safe administration of digoxin.
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