After assessing a client who is receiving an amiodarone ...

[go.lag]

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings:
 
  Vital Signs
  Nursing Assessment
  Time: 0800
  Temperature: 98  F
  Heart rate: 68 beats/min
  Blood pressure: 135/60 mm Hg
  Respiratory rate: 14 breaths/min
  Oxygen saturation: 96
  Oxygen therapy: 2 L nasal cannula
 
  Time: 1000
  Temperature: 98.2  F
  Heart rate: 50 beats/min
  Blood pressure: 132/57 mm Hg
  Respiratory rate: 16 breaths/min
  Oxygen saturation: 95
  Oxygen therapy: 2 L nasal cannula
  Time: 0800
  Client alert and oriented.
  Cardiac rhythm: normal sinus rhythm.
  Skin: warm, dry, and appropriate for race.
  Respirations equal and unlabored.
  Client denies shortness of breath and chest pain.
 
  Time: 1000
  Client alert and oriented.
  Cardiac rhythm: sinus bradycardia.
  Skin: warm, dry, and appropriate for race.
  Respirations equal and unlabored.
  Client denies shortness of breath and chest pain.
  Client voids 420 mL of clear yellow urine.
  Based on the assessments, which action should the nurse take?
  a.
  Stop the infusion and flush the IV.
  b.
  Slow the amiodarone infusion rate.
  c.
  Administer IV normal saline.
  d.
  Ask the client to cough and deep breathe.

Question 2

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below:
 
  After calling for assistance and a defibrillator, which action should the nurse take next?
  a.
  Perform a pericardial thump.
  b.
  Initiate cardiopulmonary resuscitation (CPR).
  c.
  Start an 18-gauge intravenous line.
  d.
  Ask the client's family about code status.

[aidanmbrowne]

Answer to Question 1

ANS: B
IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the client's heart rate.

Answer to Question 2

ANS: B
The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.

[go.lag]

Gracias!

[amandalm]

Excellent