Title: What is the priority nursing intervention for a patient with a junctional escape rhythm? 1. ... Post by: lnb7942 on Mar 1, 2018 What is the priority nursing intervention for a patient with a junctional escape rhythm?
1. Assess the patient for symptoms associated with this rhythm. 2. Contact the physician immediately for emergency orders. 3. Eliminate caffeine from the diet. 4. Prepare for a pacemaker insertion. Question 2 Sinus bradycardia (rate 56 beats per minute) is identified in a sleeping patient on telemetry. What is the priority nursing action? 1. Awaken the patient and see how the heart rate responds. 2. Call the physician and report this dysrhythmia. 3. Check the medication administration record and see if there is a PRN medication that will improve this rhythm. 4. Call for an immediate 12-lead electrocardiogram (ECG). Question 3 The nurse sees this rhythm on a patient's cardiac monitor. For which rhythm should the nurse begin care? 1. ventricular fibrillation 2. atrial flutter 3. sinus tachycardia 4. ventricular tachycardia Question 4 The nurse is caring for a patient with ventricular tachycardia. Which care should the nurse prepare to provide to this patient? Select all that apply. 1. immediate assessment and probable emergency intervention by the nurse 2. cardioversion, if sustained and symptomatic 3. administration of a potassium channel blocker 4. close observation for one hour prior to calling the physician 5. defibrillation to convert the rhythm in the awake patient Title: What is the priority nursing intervention for a patient with a junctional escape rhythm? 1. ... Post by: Kim12345678900 on Mar 1, 2018 Correct Answer: 1 Junctional escape rhythms may be monitored if the patient is not symptomatic. It is most important to assess the patient to see how they are affected by the rhythm. Calling the physician to report the rhythm may be appropriate if the patient is symptomatic. Eliminating caffeine or preparing for a pacemaker insertion is not an appropriate action for this patient with a junctional escape rhythm. No indication of symptoms relating to the rhythm was given. Correct Answer: 1 The priority is to awaken the patient to determine how the heart rate is affected with activity as it normally should increase. The patient should be evaluated to determine how the dysrhythmia is affecting heart function. Many patients who are asymptomatic while in sinus bradycardia can be observed and require no further intervention. Common reasons for sinus bradycardia for the nurse to consider include athletic conditioning, sleep, or a conduction disorder. Notifying the physician without first assessing the patient's response would not be appropriate. Checking the medication administration is not the priority nursing action. Ordering an ECG requires a physician's prescription. Correct Answer: 1 Ventricular fibrillation is too rapid to count and is grossly irregular; P:QRS shows no identifiable P waves; the PR interval is absent, and the QRS interval is bizarre and varies in shape and direction. It is important to identify this rhythm since it is a medical emergency and is known as cardiac arrest since the heart is not pumping. Death will follow if this situation is not resolved within four minutes. This rhythm is not atrial flutter, sinus tachycardia, or ventricular tachycardia. Correct Answer: 1, 2, 3 Sustained ventricular tachycardia is a medical emergency that requires immediate intervention, particularly in patients with cardiac disease. Treatment for ventricular tachycardia includes cardioversion. Class III antidysrhythmic medications (potassium channel blockers) are typically administered. Observation prior to calling a physician is not an appropriate action when a potentially life-threatening rhythm is identified. Defibrillation is only conducted in ventricular tachycardia when the patient is pulseless; otherwise, time is taken to synchronize for cardioversion. Title: What is the priority nursing intervention for a patient with a junctional escape rhythm? 1. ... Post by: lnb7942 on Mar 1, 2018 Passed my quiz with this!
Title: What is the priority nursing intervention for a patient with a junctional escape rhythm? 1. ... Post by: Kim12345678900 on Mar 1, 2018 Tell your classmates
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