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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While monitoring bowel sounds is important for assessing gastrointestinal function, it is not the most critical parameter to monitor in a patient with leukemia.
B. Fever can indicate infection, which is a common complication in patients with leukemia due to compromised immune function from the disease and its treatments.
C. Monitoring heart rate is important, but it may not be the most crucial parameter to monitor unless there are specific cardiac concerns.
D. Skin integrity should be monitored, but it may not be the most important parameter to monitor unless there are concerns about skin breakdown or infections.
Correct Answer is D
Explanation
A. Leukemia itself doesn't necessitate contact precautions unless there are other specific infectious concerns, which are not mentioned in this scenario.
B. Ibuprofen is contraindicated in patients with low platelet counts due to the risk of bleeding. Therefore, administering ibuprofen would exacerbate the risk of bleeding in this patient.
C. Invasive procedures like rectal temperature measurements should be avoided in patients with low platelet counts due to the risk of bleeding. Thus, this intervention increases the risk of harm to the patient.
D. Patients with low platelet counts are at risk for bleeding, including gastrointestinal bleeding. Administering a stool softener can help prevent straining during bowel movements, reducing the risk of bleeding and promoting patient comfort and safety.
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