The nurse sees a life-threatening arrhythmia on a patient's cardiac monitor. Which of the following actions should the nurse take first?
Examine the patient and collect data.
Notify the health-care provider immediately.
Obtain vital signs.
Administer antiarrhythmic medication.
The Correct Answer is B
A. While assessment and data collection are important, the priority in the presence of a life-threatening arrhythmia is to initiate immediate interventions to address the situation.
B. The nurse should immediately inform the healthcare provider about the life- threatening arrhythmia to obtain further guidance and potential orders for intervention.
C. Vital signs are important, but they should not delay immediate action when a life- threatening arrhythmia is present.
D. Administering antiarrhythmic medication may be necessary, but the nurse should first notify the healthcare provider to obtain orders and guidance before administering any medications.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should prioritize the client's immediate clinical needs based on the assessment data provided.
The first action should be to address the client's agitation, which is a sign of distress and can lead to safety issues. Therefore, the nurse should first address the client's "fall precautions" to ensure safety and prevent potential harm due to the client's disorientation and agitation.
Following this, the nurse should address the client's "urine collection" for urinalysis and culture and sensitivity (C&S), as it is critical to identify the cause of the client's febrile state and incontinence of foul-smelling urine, which could indicate an infection. This will allow for appropriate antibiotic therapy to be administered based on the sensitivity results.
Correct Answer is B
Explanation
A. Showering is not typically restricted after a splenectomy. Good hygiene practices, including regular showering, are important for preventing infection.
B. Patients who have undergone a splenectomy are at increased risk of infections, particularly from encapsulated bacteria such as Streptococcus pneumoniae. Yearly flu vaccination helps reduce the risk of influenza-related complications.
C. Long-term antibiotic prophylaxis is not routinely recommended for all patients after splenectomy. Antibiotics may be prescribed in certain situations, such as for postsplenectomy sepsis prevention, but lifelong use is not standard practice.
D. Sleeping position is not directly related to infection prevention after splenectomy.
General infection prevention measures, such as vaccination and avoiding exposure to sick individuals, are more important.
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