A patient on the telemetry unit develops atrial flutter with a heart rate of 150, respirations 26, b/p 118/64 and a o2 saturation of 90% while sitting down. Which action should the nurse do FIRST?

Prepare to administer Atropine

Reassess the patient's blood pressure

Prepare to administer Adenosine IV push

Prepare to administer supplemental 02 via nasal cannula.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: Prepare to administer supplemental O2 via nasal cannula.

Choice A rationale:

Atropine is used to treat bradycardia (slow heart rate), not atrial flutter with a rapid heart rate. Administering Atropine in this scenario could potentially worsen the patient’s condition by increasing the heart rate further.

Choice B rationale:

While reassessing the patient’s blood pressure is important, it is not the most immediate action. The patient’s current blood pressure is stable (118/64), and the priority is addressing the low oxygen saturation and high respiratory rate, which indicates respiratory distress.

Choice C rationale:

Adenosine is used to treat certain types of supraventricular tachycardia by temporarily slowing the heart rate, but it is not the first-line treatment for atrial flutter. Additionally, the patient’s blood pressure is stable, and there is no indication of hemodynamic instability that would necessitate immediate rate control.

Choice D rationale:

The patient’s oxygen saturation is 90%, which is below the normal range, and they are tachypneic with a respiratory rate of 26 breaths per minute. The first action should be to administer supplemental oxygen to improve oxygenation and prevent hypoxemia-related complications. Oxygen therapy can help stabilize the patient’s condition and improve oxygen saturation levels.

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Correct Answer is B

Explanation

Choice A rationale: Epinephrine is a potent vasoconstrictor and is typically used in emergency situations such as cardiac arrest. It is not the first-line treatment for symptomatic bradycardia1.

Choice B rationale: Atropine is the first-line medication for the treatment of bradycardia. It increases the heart rate by blocking the effects of the vagus nerve on the heart1.

Choice C rationale: Adenosine is primarily used to treat supraventricular tachycardia, not bradycardia1.

Choice D rationale: Verapamil is a calcium channel blocker used to treat high blood pressure, angina, and certain heart rhythm disorders, not typically used for bradycardia1.

A. To take the tablet with a large amount of water so that it will dissolve right away B. Go to the nearest hospital and take the medication upon reaching the hospital C. To lie or sit and place one tablet under the tongue when chest pain occurs D. if one tablet does not relieve the pain in 15 minutes, the patient should go to the hospital

Correct Answer is C

Explanation

Choice A rationale: Nitroglycerin tablets are not typically taken with water. They are designed to dissolve under the tongue for quick absorption into the bloodstream6789.

Choice B rationale: It is not necessary to go to the hospital to take the medication. The medication can be taken at the onset of chest pain6789.

Choice C rationale: This is the correct instruction. At the onset of chest pain, the patient should lie or sit down and place one tablet under the tongue6789.

Choice D rationale: If one tablet does not relieve the pain in 5 minutes, a second tablet may be taken. If the pain continues for another 5 minutes, a third tablet may be used. If the patient still has chest pain after a total of 3 tablets, they should seek immediate medical attention6789.

So, the correct answer is C, after analysing all choices

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A patient on the telemetry unit develops atrial flutter with a heart rate of 150, respirations 26, b/p 118/64 and a o2 saturation of 90% while sitting down. Which action should the nurse do FIRST?

Nursing Test Bank

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