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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Restraints should be secure but not too tight to prevent injury or impaired circulation.
B. Ensuring the knot can be quickly released is critical for the client's safety in case of emergency.
C. A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk.
D. Restraints should never be tied to side rails as this can cause injury if the rails are moved.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

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.

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Naxlex Comprehensive Predictor Exams

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Correct Answer is B

Explanation

Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Correct Answer is ["A","C","D","E","G"]

Explanation

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

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In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

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