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

Answer and Explanation

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.

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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.

A. To take the tablet with a large amount of water so that it will dissolve right away B. Go to the nearest hospital and take the medication upon reaching the hospital C. To lie or sit and place one tablet under the tongue when chest pain occurs D. if one tablet does not relieve the pain in 15 minutes, the patient should go to the hospital

Correct Answer is C

Explanation

Choice A rationale: Nitroglycerin tablets are not typically taken with water. They are designed to dissolve under the tongue for quick absorption into the bloodstream6789.

Choice B rationale: It is not necessary to go to the hospital to take the medication. The medication can be taken at the onset of chest pain6789.

Choice C rationale: This is the correct instruction. At the onset of chest pain, the patient should lie or sit down and place one tablet under the tongue6789.

Choice D rationale: If one tablet does not relieve the pain in 5 minutes, a second tablet may be taken. If the pain continues for another 5 minutes, a third tablet may be used. If the patient still has chest pain after a total of 3 tablets, they should seek immediate medical attention6789.

So, the correct answer is C, after analysing all choices

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A client has with Angina has been ordered to take sublingual NTG tablets. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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?

The nurse on the unit hears an alarm sound in the client's room. Arriving in the room, the client is unresponsive. pulseless and the nurse sees the flat rhythm on the monitor. What is the FIRST action by the nurse?

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.)

A nurse is reviewing the EKG strip of a client who is hypotensive and is complaining of leg cramping. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

The nurse notes a client in supraventricular tachycardia. The patient has a pulse and the cardiac monitor is at the bedside. The nurse understands electrical intervention is indicated. What button does the nurse push to ensure the electricity is delivered on the R wave? Refer to the picture.

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate on the cardiac monitor. Which dysrhythmias should the nurse expect to find on the EKG?

A client is experiencing atrial fibrillation for 2 weeks and did not respond to medication therapy. The client is scheduled for an elective (outpatient) cardioversion. Which other procedure or test does the nurse anticipate this client will need?