H/P

Four hours after her arrival to the emergency department, the patient remains in second-degree type II heart block and her vital signs are stable. She is transferred to a telemetry unit to prepare for insertion of a permanent pacemaker later in the day. When she gets out of bed to use the restroom, she felt faint and had to sit on the floor. The nurse finds her sitting on the floor beside the commode; the patient is awake but somewhat confused. The patient is assisted back to bed. The nurse notes that the ECG monitor shows that the patient's heart rate is at 40 beats/minute and she is now in third degree heart block. The Rapid Response team is called, and preparations are made for the immediate application of a transcutaneous pacemaker (TCP).
Which nursing actions should be included in the plan of care for the patient (Select All that Apply.)

Prepare to administer epinephrine

Monitor vital signs and ECG

Reassure the patient that the Transcutaneous Pacemaker is temporary

Prepare to administer atropine

Place both transcutaneous pacemaker pads on the chest over the heart

Provide analgesia as needed after the transcutaneous pacemaker is placed

Answer and Explanation

Correct Answer : B,C,D,E,F

B. Continuous monitoring of vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is essential for assessing the patient's hemodynamic status and response to treatment.

Additionally, continuous electrocardiographic (ECG) monitoring allows for real-time assessment of cardiac rhythm and conduction abnormalities.

C. This is an important nursing action to provide comfort and reduce anxiety for the patient. Transcutaneous pacing is often used as a temporary measure to stabilize heart rate and cardiac output until more definitive treatment, such as insertion of a permanent pacemaker, can be performed.

D. Atropine is another medication commonly used in ACLS protocols for symptomatic bradycardia and heart block. It acts to increase heart rate by blocking vagal tone. However, its effectiveness in third- degree heart block may be limited, and transcutaneous pacing is often the preferred intervention in this situation.

E. Correct placement of transcutaneous pacemaker pads is crucial for effective pacing. The pads should be placed on the chest over the heart to deliver electrical impulses and stimulate myocardial contraction. Proper placement ensures optimal pacing effectiveness and patient safety.

F. This nursing action addresses the patient's comfort and pain management following the placement of the transcutaneous pacemaker. The procedure may cause discomfort or pain, and appropriate analgesia should be provided to alleviate any discomfort and promote patient comfort.

A. Epinephrine is a medication commonly used in advanced cardiac life support (ACLS) protocols for bradycardia and heart block. In this scenario, the patient's heart rate has decreased to 40 beats/minute, indicating symptomatic bradycardia and potential hemodynamic instability. Epinephrine may be administered to increase heart rate and improve cardiac output.

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Correct Answer is D

Explanation

D Sedatives are typically administered alongside neuromuscular blockers to ensure the patient's comfort and prevent awareness during mechanical ventilation.

A The absence of a cough reflex when suctioned is expected in a patient receiving cisatracurium (Nimbex) because it is a neuromuscular blocking agent that induces paralysis. Cisatracurium inhibits skeletal muscle movement, including the muscles involved in coughing.

B An oxygen saturation between 90% to 93% is within an acceptable range for a patient in this condition.

C The lack of response to voice may indicate that the patient is sedated or experiencing effects from the neuromuscular blocking agent. However, since the patient is receiving cisatracurium to prevent asynchronous breathing with the positive pressure ventilator, it's expected that the patient will not respond to voice due to the medication-induced paralysis.

A. Respiratory rate 22 breaths/min B. Heart rate 106 beats/min C. 02 saturation of 99% D. Crackles audible at lung bases

Correct Answer is D

Explanation

D Crackles audible at the lung bases indicate the presence of pulmonary edema or fluid accumulation in the alveoli, which can compromise gas exchange and exacerbate respiratory distress. In a patient with ARDS, crackles suggest worsening pulmonary status and may indicate inadequate ventilation or oxygenation despite mechanical ventilation. Therefore, crackles at the lung bases are the most important finding to report to the healthcare provider as they may indicate a need for adjustments to the ventilator settings or additional interventions to optimize respiratory function and prevent further deterioration.

A respiratory rate of 22 breaths/min may be within an acceptable range, particularly considering that the patient is receiving mechanical ventilation. However, any significant deviation from the baseline respiratory rate or signs of respiratory distress, such as increased work of breathing or accessory muscle use, should be closely monitored and reported promptly.

B A heart rate of 106 beats/min may be within an acceptable range, although it is slightly elevated. Tachycardia can occur due to various factors, including pain, anxiety, fever, or hypoxemia. While tachycardia warrants close monitoring, it may not be the most critical finding to report unless it is associated with hemodynamic instability or other concerning symptoms.

C An oxygen saturation of 99% indicates adequate oxygenation, which is reassuring, particularly in a patient with acute respiratory distress syndrome (ARDS). However, oxygen saturation alone may not reflect the adequacy of ventilation or the severity of the underlying lung injury. Therefore, while oxygen saturation should be monitored closely, it may not be the most critical finding to report unless it declines significantly or is accompanied by other concerning symptoms.

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Naxlex Comprehensive Predictor Exams

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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