Read orders by the prescriber and answer the question.
Prescriber's orders
Labs: PT, PTT, INR
Unsupervised ambulation every 1 hr
Give protamine sulfate STAT
Give Aspirin orally daily
Continue unrestricted regular diet
Give vitamin K STAT
Initiate bleeding precautions
A nurse is admitting a client who has been in Atrial Fibrillation for 24 hours.
Which of the following interventions does the nurse plan to complete?
(Select All that Apply.)
Give vitamin K STAT
Prepare to place the client on a Heparin drip
Draw labs: PT, PTT, INR
Prepare to administer Coumadin
Prepare to administer Verapamil
Correct Answer : A,B,C,D
Choice A rationale: Vitamin K is given to counteract the effects of anticoagulants like warfarin, which might have been administered to manage atrial fibrillation1.
Choice B rationale: Heparin is an anticoagulant often used in the initial management of atrial fibrillation to prevent the formation of clots2.
Choice C rationale: PT, PTT, and INR are lab tests used to monitor the effectiveness of anticoagulation therapy1.
Choice D rationale: Coumadin (warfarin) is a long-term anticoagulant therapy often used in the management of atrial fibrillation1.
Choice E rationale: Verapamil is a calcium channel blocker, not typically the first line of treatment for atrial fibrillation3.
So, the correct answer is Choices A, B, C, and D, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale: Vitamin K is given to counteract the effects of anticoagulants like warfarin, which might have been administered to manage atrial fibrillation1.
Choice B rationale: Heparin is an anticoagulant often used in the initial management of atrial fibrillation to prevent the formation of clots2.
Choice C rationale: PT, PTT, and INR are lab tests used to monitor the effectiveness of anticoagulation therapy1.
Choice D rationale: Coumadin (warfarin) is a long-term anticoagulant therapy often used in the management of atrial fibrillation1.
Choice E rationale: Verapamil is a calcium channel blocker, not typically the first line of treatment for atrial fibrillation3.
So, the correct answer is Choices A, B, C, and D, after analyzing all choices.
Correct Answer is D
Explanation
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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