You are the nurse working on the telemetry unit and you have finally gotten to sit down to work on some charting. Suddenly the heart monitors at the
... [Show More] station start beeping. Patient in room 18 is showing this rhythm on the monitor. The medical team advances together into the room and finds them unconscious. What is priority action by the nurse?
A) Prepare to administer adenosine to the patient
B) Begin chest compressions
C) Prepare for defibrillation
D) Check for a pulse
Answer: D
A pulse would be assessed for first. Then the patient will be defibrillized and chest compressions will begin immediately.
The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses consciousness. The patient is defibrillated, and the rate returns as the following. What should the nurse do first?
A) Begin compressions
B) Shock the client again immediately
C) Prepare for intubation
D) Administer adenosine
Answer: A
Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not initiated. The client may need to be shocked again, but chest compressions must begin first.
The patient with a history of hypertension and diabetes has the following rhythm strip. The patient's vitals are as follows: BP 145/89, HR 90, SpO2 95%, RR 19. Which of the following does the nurse expect to do at this time?
a) Prepare the client for cardioversion STAT
b) Begin administering anticoagulants
c) Grab the crash cart for administration of adenosine
d) Teach the client about possibility of pacemaker installation
Answer: B
Atrial flutter places the client at high risk for development of clot formation in the atria. Because the client is stable at this time, cardioversion or adenosine would not be performed at this time. Before cardioversion can occur in a patient, anticoagulant therapy should be begun at least 48 hours beforehand if possible.
The nurse is preparing to administer adenosine to the patient with the following rhythm which is symptomatic. What should the nurse plan on having in the patient room? Select All That Apply:
a) Physician
b) Crash cart
c) IV pump
d) EKG monitor
e) Lidocaine
Answer: A, B, and D
Adenosine is administered as a very quick IV push. The physician must be present in the room and the crash cart must be on hand. An ekg monitor should be in the room to monitor the effectiveness of the medication.
The nurse has just administered adenosine via IV push and sees the following rhythm on the monitor. What is the nurse's priority intervention?
a) Apply conductive gel and defibrillate the patient
b) Document the findings and continue to monitor
c) Administer another mg of the medication
d) Begin chest compressions
Answer: B
This finding would be expected upon administration of adenosine. The rhythm should then begin again in some other rhythm, hopefully normal sinus rhythm. It would be important to document the exact time of this change and continue to monitor the change back to NSR. If this change does not occur, or if another rhythm is produced, appropriate action would then be taken based on the result.
A group of nursing students are discussing atrial flutter. These students recognize that which of the following are seen with atrial flutter? Select all that apply:
1) Ventricular rate of 220-300 bpm.
2) Regular rhythm
3) Saw-tooth pattern
4) Measurable PR interval
5) Long QRS interval
Answer(s): 2, 3
The ATRIAL rate is 250-400 bpm. Ventricular is about 75-150. The rhythm is regular, with the P wave appearing as little flutter or a "saw tooth pattern". The PR interval is not measurable r/t this saw-tooth P wave. The QRS is normal.
A nursing student is aware that which of the following is the treatment for unstable atrial flutter?
1) Adenosine (Adenocard) 6 mg rapid IVP.
2) Cardioversion with adjacent Heparin therapy
3) Defibrillation STAT followed by CPR.
4) Altemose 3 mg IVP over 1-2 seconds.
Answer: 2
Cardioversion is used if the patient is unstable. Anticoagulants are used if the arrhythmia has stuck around for 48 hr +. Adenosine may be used with a narrow QRS and regular RR interval [Show Less]