A patient is in sinus tachycardia. Which nursing interventions ...

[iveyjurea]

A patient is in sinus tachycardia. Which nursing interventions are appropriate?
 
  Select all that apply.
  1. Observe the patient for effects on cardiac function.
  2. Administer two tablets of acetaminophen (Tylenol) per physician prescription if an elevated temperature is present.
  3. Administer normal saline 0.9 IV at the prescribed rate of 200 mL per hour if hypovolemia is suspected as the cause.
  4. Give pain medications as prescribed if pain is present.
  5. Give atropine per physician prescription to slow the heart rate.

Question 2

The nurse is notified by the cardiac monitoring technician that a patient on continuous cardiac monitoring is having frequent alarms. When the nurse enters the patient's room, the patient is in no apparent distress, is sitting in the chair and eating.
 
  Which are appropriate nursing interventions?
  Select all that apply.
 
  1. Confirm that lead wires are properly connected.
  2. Assess placement of electrodes.
  3. Remove and reapply new electrodes if nonadherent.
  4. Assess skin sites and move an electrode if the skin appears irritated.
  5. Call for assistance.

[jjorrostieta]

Answer to Question 1

Correct Answer: 1, 2, 3, 4
Appropriate nursing interventions for the patient in sinus tachycardia are to observe the patient for effects on cardiac function and to treat fever, hypovolemia, and pain if present. The focus is on determining the patient response to the elevated heart rate and treating the underlying causes, which are often fever, pain, and hypovolemia. Atropine acts to increase heart rate and may be a cause of sinus tachycardia.

Answer to Question 2

Correct Answer: 1, 2, 3, 4
Alarms may be triggered by loose or disconnected lead wires, poor electrode contact, excessive movement, electrical interference, or equipment malfunction. Nursing actions include assessing lead wire connections; assessing placement of electrodes and changing electrodes every 24 to 48 hours or removing and reapplying electrodes that are dislodged or non-adherent; assessing and documenting skin condition under the pads and moving pads to alternate sites to avoid skin irritation; and documenting ECG strips according to unit policy. Since the patient is in no apparent distress, assistance is not required.

[iveyjurea]

TYSM

[nguyenhoanhat]

Excellent