A client who was admitted with rapid atrial flutter is receiving amiodarone 1 mg/minute via a peripheral IV infusion in the left hand. The unlicensed assistive personal (UAP) reports to the nurse that the client's heart rate is 90 beats/minute and blood pressure is 110/50 mm Hg. Which intervention should the nurse implement?
Tell the UAP to turn off the amiodarone.
Evaluate rhythm of client's heat rate.
Determine regularity of peripheral pulses.
Restart the IV infusion in another site.
The Correct Answer is B
A. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.
B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.
C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.
D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E","G"]
Explanation
A. Encouraging the client to sit up and ambulate helps prevent complications such as atelectasis and deep vein thrombosis by promoting lung expansion and blood circulation.
B. While monitoring for bleeding is important, in most stable postoperative cases, continuous monitoring isn't necessary. Once daily checks are often sufficient.
C. Regular use of the incentive spirometer helps prevent respiratory complications such as pneumonia by promoting deep breathing and lung expansion.
D. Adequate hydration is essential for wound healing, preventing urinary retention, and maintaining overall physiological function. Encourage the client to drink fluids within their prescribed limits.
E. Monitoring for sedation after administering pain medications is crucial to ensure the client's safety and prevent respiratory depression. Assess the client's level of consciousness, respiratory rate, and oxygen saturation regularly.
F. Neurological assessments are usually not required this frequently unless there are specific concerns.
G. Administering pain medication after activity helps manage postoperative pain effectively, enabling the client to participate in necessary activities such as ambulation and respiratory exercises. It's important to ensure that pain is adequately controlled to facilitate recovery and promote comfort.
Correct Answer is B
Explanation
A. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.
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