A patient in the emergency department has a cardiac rhythm strip that reveals a junctional rhythm with rate of 128,PR interval of 0.08 seconds,a normally configured QRS,and an upright T wave.The patient is awake and alert with warm,dry skin.Which nursing intervention is indicated?
A)Prepare for immediate cardioversion
B)Immediate notification of the rapid response team
C)Continued monitoring and assessment
D)Administration of potassium by slow intravenous infusion

Question

Quizplus · Accepted Answer

The patient's junctional rhythm with a rate of 128 may be a normal variant or may be due to underlying conditions, such as medication toxicity, MI or digitalis toxicity. However, the patient is awake, alert and has warm, dry skin - all signs that the patient is well perfused and the cardiac output is adequate. The nursing intervention indicated in this case is continued monitoring and assessment to determine the cause of the junctional rhythm and to monitor for any changes in the patient's condition. Immediate cardioversion and notifying the rapid response team are not indicated at this time. While low potassium levels can cause rhythm disturbances, there is no evidence in this case to suggest hypokalemia as the underlying cause.

A Patient in the Emergency Department Has a Cardiac Rhythm