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 D

Explanation

Choice A rationale: First-degree AV block is a type of heart block, not a dysrhythmia associated with palpitations, fatigue, and dizziness12.

Choice B rationale: Sinus bradycardia is a slow heart rate, not a rapid and irregular one12.

Choice C rationale: Sinus tachycardia is a fast heart rate but it is regular, not irregular12.

Choice D rationale: Atrial fibrillation is a fast and irregular heart rate, which aligns with the symptoms described34.

So, the correct answer is Choice D, after analysing all choices.

A. Reinforce education provided by RN B. Give oral medication C. obtain vital signs on stable patient D. Starting a blood transfusion

Correct Answer is D

Explanation

Choice A rationale: LPNs can reinforce education provided by RNs56.

Choice B rationale: LPNs can administer medications that are not high-risk56.

Choice C rationale: LPNs can obtain vital signs on stable patients56.

Choice D rationale: Starting a blood transfusion is a task that requires specific nursing judgment and decision-making skills, which should not be delegated to an LPN56.

So, the correct answer is Choice D, after analyzing 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?

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate on the cardiac monitor. Which dysrhythmias should the nurse expect to find on the EKG?

Correct Answer is D

Explanation

As the registered nurse, which tasks below should you NOT delegate to the LPN?

Correct Answer is D

Explanation

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