A patient admitted with urosepsis and alcohol abuse had three seconds of PVCS and returns to sinus tachycardia. The patient's baseline heart rate ie 116/ min with a temperature of 101.1F, respirations of 22/min and blood pressure is 114/64. What should the nurse anticipate to do first?
Administer amiodarone IV
Start Carotid massage
Administer Tylenol
Assess patient LOC
The Correct Answer is D
D. Assessing the patient's level of consciousness (LOC) is essential to determine their neurological status and assess for any signs of deterioration. Changes in LOC could indicate worsening sepsis, hypoperfusion, or other underlying issues that require immediate attention.
A. Administering amiodarone, an antiarrhythmic medication, is not the first action to take in this situation. While amiodarone may be used to manage certain arrhythmias, its use should be based on a thorough assessment and specific arrhythmia diagnosis. In this case, with only three seconds of PVCs followed by sinus tachycardia, immediate administration of amiodarone is not warranted.
B. Carotid massage is not indicated in this scenario. Carotid massage is typically used to slow down or terminate supraventricular tachycardias (SVTs), such as paroxysmal supraventricular tachycardia (PSVT). However, it is contraindicated in patients with a history of stroke, transient ischemic attack (TIA), carotid artery disease, or recent myocardial infarction (MI). Furthermore, PVCs are not typically responsive to carotid massage.
C. Administering Tylenol (acetaminophen) may be appropriate in this situation. The patient's elevated temperature (101.1°F) suggests the presence of fever, which could contribute to the patient's tachycardia. Lowering the fever with acetaminophen may help reduce the heart rate and alleviate symptoms associated with fever, such as discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. A pulmonary artery catheter is used to monitor hemodynamic status. It provides valuable information about cardiac function, preload, afterload, and cardiac output. By measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, and central venous pressure, a pulmonary artery catheter helps assess the effectiveness of cardiac function and guide management in critically ill patients, especially those with conditions such as heart failure, shock, or pulmonary hypertension.
A. A pulmonary artery catheter, also known as a Swan-Ganz catheter, is not used to monitor intracranial pressure. Instead, it is primarily used to assess hemodynamic status and cardiac function by measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, central venous pressure, and cardiac output.
B. A pulmonary artery catheter is not used to directly monitor renal function. While changes in hemodynamic status can impact renal perfusion and function, the primary purpose of a pulmonary artery catheter is to assess cardiac function and hemodynamics, rather than renal function.
C. A pulmonary artery catheter is not used to monitor spinal cord perfusion. Although alterations in hemodynamic status can affect spinal cord perfusion indirectly, the main purpose of a pulmonary artery catheter is to evaluate cardiac function and hemodynamics.
Correct Answer is D
Explanation
D. Asystole represents the absence of electrical activity in the heart and is not amenable to defibrillation. Therefore, the RRT would continue cardiopulmonary resuscitation (CPR) with chest compressions and may administer medications or other interventions as indicated. This statement provides accurate information to the family about the patient's condition and the actions being taken by the RRT.
A. Defibrillation is not indicated for asystole. Asystole represents a flatline on the cardiac monitor, indicating the absence of electrical activity in the heart. Defibrillation is only effective for certain types of cardiac rhythms, such as ventricular fibrillation or pulseless ventricular tachycardia. Therefore, the RRT would not use defibrillation for a patient in asystole.
B. It does not provide the family with information about the patient's condition or the actions being taken by the RRT. Moreover, excluding the family from the patient's care may cause additional distress and prevent them from being present to support their loved one during a critical situation.
C. Cardiopulmonary resuscitation (CPR) is performed to maintain blood flow and oxygenation to vital organs during cardiac arrest. However, it does not restore normal blood flow or circulation. The goal of CPR is to provide temporary support until advanced interventions can be initiated or until return of spontaneous circulation (ROSC) is achieved.
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