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 A

Explanation

Choice A rationale: Heparin is an anticoagulant that prevents new clots from forming but does not dissolve existing clots23.

Choice B rationale: Heparin does not directly dissolve clots23.

Choice C rationale: While a pharmacist can provide medication information, it is incorrect to say they would be a better fit to answer this question as nurses are trained in medication education23.

Choice D rationale: While it’s true that it takes time for heparin to reach a therapeutic blood level, this statement could be misleading because heparin does not dissolve clots23.

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

A. Shortness of breath B. Hypotension C. Hypertension D. Chest Pain E. Dizziness F. Bounding pulses

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale: Shortness of breath is a common symptom in atrial fibrillation due to the heart’s inability to pump blood effectively12.

Choice B rationale: Hypotension can occur in atrial fibrillation due to decreased cardiac output12.

Choice C rationale: Hypertension is not typically a direct result of atrial fibrillation. However, long-term untreated hypertension can be a cause of atrial fibrillation12.

Choice D rationale: Chest pain can occur in atrial fibrillation due to decreased blood flow to the heart12.

Choice E rationale: Dizziness is a common symptom in atrial fibrillation due to decreased blood flow to the brain12.

Choice F rationale: Bounding pulses are not typically associated with atrial fibrillation12.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has developed a thrombus and is receiving heparin by continuous N infusion. The client asks the nurse how long will it take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

Correct Answer is A

Explanation

A client has developed atrial fibrillation with a ventricular rate of 148 beats per minute. Which assessment findings does the nurse expect to find in this client? Select all that apply (Select All that Apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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