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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Tight fitting clothes may put pressure on the T-tube insertion site and interfere with drainage. Loose-fitting clothing is recommended.
B. Showering is typically preferred over baths to keep the T-tube site clean and dry.

Baths may increase the risk of infection.

C. Regular emptying of the drainage bag helps prevent excessive weight, which can pull on the T-tube and cause discomfort or displacement. However, it should necessarily be emptied at the same time each day.
D. Securing the tubing to clothing helps prevent accidental dislodgment or pulling on the T-tube, reducing the risk of complications.

A. Encourage the client to consume at least 2 L of fluid daily. B. Monitor intake and output hourly C. Provide ibuprofen for retroperitoneal discomfort. D. Provide a diet high in protein.

Correct Answer is B

Explanation

A. In the oliguric phase of acute kidney injury, fluid intake may need to be restricted rather than encouraged to prevent fluid overload.
B. Hourly intake and output monitoring is crucial for managing fluid balance and assessing the progression of kidney injury. Close monitoring can help prevent fluid overload, which is a risk due to the reduced urine output. It also aids in the timely adjustment of fluid administration and the detection of any changes in the client's condition that may necessitate intervention.
C. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are contraindicated in acute kidney injury as they can further impair renal function.

D. In the oliguric phase, protein intake may need to be restricted to reduce the workload on the kidneys and minimize azotemia. A high-protein diet can increase the burden on already compromised kidneys due to the increased production of urea, a byproduct of protein metabolism that requires excretion by the kidneys.

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The nurse sees a life-threatening arrhythmia on a patient's cardiac monitor. Which of the following actions should the nurse take first?

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