You are caring for this team of patients. Which patient is the priority to see first to collect data?
80-year-old male patient with a history of atrial fibrillation with rapid ventricular response whose cardiac monitor shows a heart rate of 92
66-year-old female patient with a newly inserted permanent pacemaker whose cardiac monitor shows a heart rate of 50
72-year-old male patient with an implantable cardiac defibrillator that delivered a shock 4 hours ago whose cardiac monitor shows normal sinus rhythm and a heart rate of 68
78-year-old male patient with chronic atrial fibrillation who is prescribed metoprolol (Toprol) whose cardiac monitor shows a heart rate of 58.
The Correct Answer is B
A. While atrial fibrillation with a rapid ventricular response requires attention, it is not an immediate concern unless associated with symptoms such as chest pain, shortness of breath, or hemodynamic instability.
B. A heart rate of 50 in a patient with a newly inserted permanent pacemaker may indicate bradycardia, which could be a sign of pacemaker malfunction or lead dislodgement. This patient requires immediate assessment to rule out complications.
C. While recent implantable cardioverter-defibrillator (ICD) discharge warrants evaluation, the patient is currently in normal sinus rhythm with a heart rate of 68, suggesting stability. This patient's assessment can be prioritized after the patient with the pacemaker issue is seen.
D. A heart rate of 58 in a patient with chronic atrial fibrillation on beta-blocker therapy may not be immediately concerning if the patient is asymptomatic and hemodynamically stable. This patient can be assessed after addressing the more urgent pacemaker issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
A. Bright orange urine could be caused by certain medications, such as rifampicin and phenazopyridine or food dyes, such as those containing carotene.
B. This is because the obstruction of the bile duct leads to an accumulation of bilirubin in the blood, which is then excreted in the urine, giving it a darker color.
C. Pale yellow urine is indicative of normal urine coloration and is not specific to bile duct obstruction.
D. Red urine could indicate the presence of blood, which might suggest other conditions such as urinary tract infections or kidney stones, but not typically bile duct obstruction.
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