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 2Sinus 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 3The 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 4The 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
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