An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

Give PRN lorazepam (Ativan) and cancel the transfer.

Obtain an order for restraints as needed and transfer the patient.

Notify the health care provider and postpone the transfer.

Inform the receiving nurse and then transfer the patient.

Answer and Explanation

The Correct Answer is C

C. This allows for the patient's condition to be re-evaluated, ensuring that they receive the necessary care and attention before being transferred.

A. Benzodiazepines can cause sedation, cognitive impairment, and delirium, which may worsen the patient's condition. Canceling the transfer without addressing the underlying cause of confusion may delay appropriate management.

B. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying cause of confusion. Restraints should only be considered as a last resort if all other measures to ensure patient safety have been exhausted.

D. This option is not appropriate because transferring the patient without addressing the new-onset confusion could compromise patient safety. It's essential to identify and manage the underlying cause of confusion before transferring the patient to another unit.

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Correct Answer is A

Explanation

A. Atropine is commonly used in the treatment of symptomatic bradycardia. It works by blocking vagal stimulation, leading to increased heart rate. Atropine is typically administered in doses of 0.5 to 1 mg every 3 to 5 minutes, up to a total dose of 3 mg, in patients with symptomatic bradycardia.

B. Sodium bicarbonate is not indicated for symptomatic bradycardia. It is primarily used in the management of metabolic acidosis, hyperkalemia, and certain drug overdoses. While sodium bicarbonate may be administered in specific situations during cardiopulmonary resuscitation (CPR), it is not the first-line treatment for symptomatic bradycardia.

C. Magnesium sulfate is used in the treatment of certain arrhythmias, such as torsades de pointes and refractory ventricular fibrillation or ventricular tachycardia associated with hypomagnesemia. However, it is not the first-line treatment for symptomatic bradycardia. Magnesium sulfate may be considered if there are specific indications such as torsades de pointes or suspected hypomagnesemia.

D. Epinephrine is commonly used in advanced cardiac life support (ACLS) protocols for cardiac arrest. It is not the first-line treatment for symptomatic bradycardia. Epinephrine is primarily used during CPR to improve coronary and cerebral perfusion by increasing systemic vascular resistance and heart rate.

However, in the case of symptomatic bradycardia, atropine is typically preferred as the initial medication.

A. Administer amiodarone IV B. Start Carotid massage C. Administer Tylenol D. Assess patient LOC

Correct Answer is D

Explanation

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.

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An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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