Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be
... [Show More] reached in the
morning
Administer the medication but consult the primary health care provider when he
becomes available - ANSWER Ask the answering service to contact the on-call
primary health care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who believes
that a primary health care provider's prescription may be in error is responsible for
clarifying the prescription before carrying it out. Therefore the nurse would not
administer the medication; instead, the nurse would withhold the medication until the
dose can be clarified. The nurse would not wait until the next morning to obtain
clarification. It is premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit.
The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the
monitor, checks the client's carotid pulse, and determines that the PVCs are not
perfusing. What is the nurse's most appropriate action?
Document the findings
Ask the ED primary health care provider to check the client
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI - ANSWER Ask the ED primary
health care provider to check the client
Rationale: The most appropriate action by the nurse would be to ask the ED health care
provider to check the client. PVCs are a result of increased irritability of ventricular cells.
Peripheral pulses may be absent or diminished with the PVCs themselves because the
decreased stroke volume of the premature beats may in turn decrease peripheral
perfusion. Because other rhythms also cause widened QRS complexes, it is essential
that the nurse determine whether the premature beats are resulting in perfusion of the
extremities. This is done by palpating the carotid, brachial, or femoral artery while
observing the monitor for widened complexes or by auscultating for apical heart sounds.
In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore, the
nurse would not tell the client that the PVCs are expected. Although the nurse will
continue to monitor the client and document the findings, these are not the most
appropriate actions of those provided.
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse
checks the client's record a [Show Less]