A client in the coronary care unit is receiving a diltiazem infusion for atrial fibrillation. The nurse observes on the cardiac monitor that the client's heart rate has converted to sinus bradycardia at a rate of 50 beats/minute. Which nursing action should be performed first?

Apply transcutaneous pacemaker pads.

Place the client in Trendelenberg position.

Call the doctor for an order to decrease the infusion rate.

Administer a dose of atropine.

Answer and Explanation

The Correct Answer is C

A. Apply transcutaneous pacemaker pads: While this is a potential intervention for symptomatic or severe bradycardia unresponsive to medications, it is premature as a first step in this scenario. The client is stable with a heart rate of 50 bpm and no mention of hemodynamic compromise.

B. Place the client in Trendelenburg position: This position is used to improve venous return in hypotensive patients, but there is no evidence of hypotension or poor perfusion. It is not an appropriate response to mild bradycardia in this context.

C. Call the doctor for an order to decrease the infusion rate: Diltiazem is a calcium channel blocker that slows AV node conduction, potentially causing bradycardia. Since the heart rate has dropped to 50 bpm, the most appropriate first action is to contact the provider to adjust the infusion rate, which may be too high for the client’s current rhythm.

D. Administer a dose of atropine: Atropine is used for symptomatic bradycardia. If the client is asymptomatic and the bradycardia is mild and medication-induced, adjusting or discontinuing the offending agent should be attempted before administering atropine.

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Correct Answer is D

Explanation

A. Dopamine and 50% non-rebreather mask: Dopamine is a vasopressor used in hypotension or shock, an inotropic agent used to improve cardiac output, not typically first-line for anxiety or respiratory distress. A non-rebreather mask may provide high oxygen levels but can be overwhelming and exacerbate anxiety if not well tolerated.

B. Nesiritide IV infusion and digoxin PO: Nesiritide is a vasodilator which may reduce preload and afterload in heart failure, and digoxin is a positive inotrope that can improve contractility, but neither offers rapid relief for anxiety and dyspnea. These medications have slower onset and are not used primarily for symptom control in acute distress.

C. Diazepam IV push and metoprolol IV: While diazepam may reduce anxiety, it can depress respiration, which is dangerous in decompensated heart failure with potential pulmonary edema. Metoprolol reduces heart rate and contractility and must be used cautiously in acute settings.

D. Morphine IV and oxygen 2 liters via nasal cannula: Morphine reduces preload, anxiety, and the sensation of breathlessness, making it ideal in acute decompensated heart failure. Low-flow oxygen improves oxygenation without overwhelming the patient. This combination directly targets both physiologic and psychological distress.

A. Administer amiodarone IV push followed by a continuous infusion. B. Establish unresponsiveness and check the carotid pulse. C. Immediately defibrillate the client using the synchronous mode. D. Initiate a rapid response call and increase the monitor's sensitivity.

Correct Answer is B

Explanation

A. Administer amiodarone IV push followed by a continuous infusion: Amiodarone is part of the Advanced Cardiac Life Support (ACLS) algorithm for ventricular fibrillation (VF) or pulseless ventricular tachycardia, but it should only be given after confirming the rhythm and initiating basic life support steps, including pulse check.

B. Establish unresponsiveness and check the carotid pulse: The rhythm strip shows ventricular fibrillation, a life-threatening arrhythmia. However, before initiating advanced interventions such as defibrillation, the nurse must first confirm the client is unresponsive and pulseless, which is the correct initial action according to ACLS protocols.

C. Immediately defibrillate the client using the synchronous mode: Defibrillation is the correct treatment for VF, but it must be done in unsynchronized mode. Additionally, it is not appropriate to defibrillate until pulselessness is confirmed. Synchronized mode is used for rhythms like unstable SVT or atrial fibrillation not VF.

D. Initiate a rapid response call and increase the monitor’s sensitivity: A rapid response team is called for deteriorating patients who are still responsive. If the client is unresponsive and pulseless, a code blue or cardiac arrest protocol should be initiated, not just a rapid response. Monitor sensitivity adjustments are irrelevant in a confirmed life-threatening rhythm.

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WBC	8.5
Hemoglobin	17g/dL
Hematocrit	54%
BUN	28mg/dL
Creatinine	1.1 mg/dL
Potassium	4.9 mEq/L

A client in the coronary care unit is receiving a diltiazem infusion for atrial fibrillation. The nurse observes on the cardiac monitor that the client's heart rate has converted to sinus bradycardia at a rate of 50 beats/minute. Which nursing action should be performed first?

Nursing Test Bank

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