Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best?
Stop and ventilate the patient with 100% oxygen.
Check the patient's potassium level
Give prescribed PRN antidysrhythmic medications.
Decrease the suction pressure to 80 mm Hg.
The Correct Answer is A
Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.
B. Check the patient's potassium level in (option B) is incorrect because While electrolyte imbalances, including low potassium levels (hypokalemia), can contribute to cardiac dysrhythmias, checking the potassium level is not the immediate priority when PVCs occur during suctioning.
C. Give prescribed PRN antidysrhythmic medications in (option C) is incorrect because: Administering antidysrhythmic medications without further assessment or evaluation may not be appropriate in this situation.
D. Decrease the suction pressure to 80 mm Hg in (option D) is incorrect because: While adjusting suction pressure may help prevent further irritation, it is not the initial priority when PVCs are present during suctioning.
E. Documenting the dysrhythmia in the patient's chart in (option E) is incorrect because: Documentation is important but should not be the initial action when a patient experiences PVCs during suctioning. Patient safety and immediate intervention take precedence.
Therefore, when PVCs occur during suctioning, the nurse should stop the procedure, provide ventilatory support with 100% oxygen, and assess the patient's response to intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Norepinephrine is a potent vasoconstrictor and inotropic agent commonly used to increase blood pressure in cases of hypotension or shock. However, if the infusion rate is too high, it can lead to excessive vasoconstriction and potentially compromise organ perfusion.
A heart rate of 58 beats/min suggests bradycardia, which can be an indication of excessive vasoconstriction caused by a high dose or rate of norepinephrine infusion. Excessive vasoconstriction can reduce cardiac output and worsen tissue perfusion.
A. Mean arterial pressure is 55 mm Hg in (option A) is incorrect because A mean arterial pressure of 55 mm Hg may be within an acceptable range for a patient receiving norepinephrine infusion, depending on the patient's baseline blood pressure and clinical condition.
B. Systemic vascular resistance (SVR) is elevated in (option B) is incorrect because An elevated SVR indicates increased peripheral vascular resistance and can be a desired effect of norepinephrine infusion to improve blood pressure and perfusion.
C. Pulmonary artery wedge pressure (PAWP) is low in (option C) which is incorrect because A low PAWP may indicate decreased left ventricular preload, which can be a desired effect of norepinephrine infusion to reduce fluid overload in certain clinical conditions.
It is important for the nurse to carefully monitor the patient's hemodynamic parameters, including blood pressure, heart rate, and organ perfusion when titrating norepinephrine infusion to ensure optimal dosing and minimize potential adverse effects. If concerns arise regarding the infusion rate, the healthcare provider should be promptly notified for further evaluation and adjustment of the treatment plan.
Correct Answer is A
Explanation
This pathway represents the normal sequence of electrical impulses that coordinate the contraction and relaxation of the heart chambers.
The electrical signal originates from the sinoatrial (SA) node, which is often referred to as the natural pacemaker of the heart. It is located in the right atrium and generates the electrical impulses that initiate each heartbeat. From the SA node, the electrical signal travels to the atrioventricular (AV) node, which is located at the junction between the atria and ventricles.
After passing through the AV node, the electrical impulse travels through the bundle of His (also known as the atrioventricular bundle) and divides into the right and left bundle branches. These branches continue the conduction pathway and deliver the electrical signal to the Purkinje fibers.
The Purkinje fibers spread the electrical impulse rapidly throughout the ventricles, stimulating the contraction of the ventricular muscle and allowing for efficient pumping of blood out of the heart.
Therefore, the correct sequence of the normal conduction pathway in the heart is:
A. SA node - AV node - bundle of His - bundle branches - Purkinje fibers.
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