Your client: Chester Payne
Age: 78 years old
Past medical history. History of persistent atrial fibrillation, hypertension, hyperlipidemia and osteoarthrosis.
Yesterday: Client was admitted for a diagnosis of atrial fibrillation with rapid ventricular response (RVR). Later in the day, the client's heart rhythm was converted to normal sinus rhythm using intravenous medication therapy.
0900 today: Client is sitting up in the bedside recliner. Client reports "racing heartbeat" and feeling "like I can't get a good deep breath" Upon auscultation the nurse hears an irregular heart rhythm.
Assessment is as follows:
Neurological: Alert and oriented x 4
Eyes, Ear, Nose, and Throat (EENT): Normocephalic, denies sore throat, denies nasal congestion, denies vision changes. No swelling or drainage visualized.
Pulmonary: Reports some shortness of breath (SOB), no cough. Lungs sound clear in all fields. Cardiovascular: Irregular heart rhythm auscultated. Denies chest pain. Skin is warm and dry to the touch. Capillary refill > 3 seconds. 2+ bilateral lower extremity edema. Peripheral pulse 1+ equal bilaterally. Jugular vein distention (JVD) is noted
Gastrointestinal: Abdomen rounded and firm. Reports slight nausea, bowel sounds hypoactive x 4 quadrants. Reports bowel movement prior to admission.
Genitourinary: Voiding clear yellow urine without issues as per client self-report.
Musculoskeletal: Full range of motion against resistance.
What is the next action the nurse should take?
Obtain manual blood pressure
Measure airflow via incentive spirometry
Insert indwelling urinary catheter
Assist the patient to get dressed to work with physical therapy
The Correct Answer is A
A. Obtain manual blood pressure: Assessing the hemodynamic status is the priority when a client reports a racing heartbeat and shortness of breath. An irregular rhythm following conversion of atrial fibrillation requires immediate validation of perfusion and blood pressure stability. Manual measurement provides the most accurate clinical data for determining the severity of the cardiovascular change.
B. Measure airflow via incentive spirometry: Incentive spirometry is used to prevent atelectasis and is not a diagnostic tool for acute shortness of breath or cardiac arrhythmias. It does not provide information regarding the underlying cause of the "racing heartbeat" or the irregular rhythm. Priority must be placed on cardiovascular assessment rather than routine respiratory exercises.
C. Insert indwelling urinary catheter: There is no immediate clinical indication for an invasive urinary catheter based on the client's current symptoms of palpitations and dyspnea. While monitoring output is important in heart failure, it is secondary to stabilizing the client's heart rate and rhythm. Catheterization poses an unnecessary infection risk in this acute assessment phase.
D. Assist the patient to get dressed to work with physical therapy: Engaging in physical exertion while experiencing tachycardia and shortness of breath is dangerous and contraindicated. The client's reports of a "racing heartbeat" and irregular rhythm indicate a potential relapse into atrial fibrillation with rapid response. Physical activity should be deferred until the client is hemodynamically stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Irregular heart beat with a rate of 86 bpm: While a rate of 86 is within the normal range, the persistence of an irregular rhythm indicates that the client has not returned to normal sinus rhythm. The primary goal of therapy includes rhythm stabilization or better rate control. An irregular rhythm still suggests a deviation from the previous day's successful conversion.
B. No edema noted in the bilateral extremities: The resolution of peripheral edema is a direct indicator that diuretic therapy and heart failure management have been effective. It demonstrates that the excess fluid has been successfully mobilized and excreted from the body. This finding confirms an improvement in the client's congestive state.
C. hypoactive bowel sounds in all 4 quadrants: Hypoactive bowel sounds were present at the start of the assessment and their persistence does not indicate a successful cardiovascular intervention. This finding is likely unrelated to the primary cardiac issue or may be a side effect of other medications. Improvement in cardiac output usually improves systemic perfusion, including the gut.
D. Decreased urine output: Successful treatment with a diuretic like furosemide should result in increased, not decreased, urine output. A decrease in output would suggest worsening renal perfusion or a lack of response to the medication. Effective management of heart failure aims to reduce fluid volume through diuresis.
Correct Answer is D
Explanation
A. Insert a 20-gauge peripheral IV catheter: Establishing venous access is necessary for administering intravenous diuretics but is not the most immediate action. Assessment of the clinical status must precede invasive interventions to determine the severity of the fluid overload. The nurse should prioritize gathering objective data on respiratory compromise before performing venipuncture.
B. Administer oxygen at 2 liters per minute via nasal cannula: The current oxygen saturation is 94% on room air, which is generally considered acceptable for many patients. While supplemental oxygen may be indicated later, it is not the most critical first step given these stable saturation levels. Respiratory assessment should guide the necessity and titration of oxygen therapy.
C. Place the client on a cardiac monitor: Continuous cardiac monitoring is important for detecting arrhythmias associated with heart failure or electrolyte shifts. However, it does not provide immediate information regarding the patient's primary risk of pulmonary congestion or respiratory distress. Monitoring is an adjunctive task rather than the primary diagnostic priority.
D. Auscultate the client's breath sounds: Assessing for crackles or diminished sounds is the priority to determine the extent of pulmonary edema. This assessment provides immediate data on the severity of the fluid-volume overload and the risk of respiratory failure. Objective respiratory findings are essential for prioritizing subsequent medical and nursing interventions.
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