The charge nurse on a telemetry unit is training a new registered nurse (RN). The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first?

Question

Quizplus · Accepted Answer

11ecbb05_cbc0_715e_b433_dfc0c454145d_MD0009_00 Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP). (Option A) The client with atrial fibrillation (AF) should be seen after the MI client. Vital signs are stable, but the International Normalized Ratio (INR) should be lower (therapeutic range of 2.0-3.0 for AF). The nurse should assess for signs of bleeding and notify the HCP; the scheduled dose of warfarin should likely be held. (Option B) A temperature of 99 F (37.2 C) is not uncommon in the days immediately following surgery. The nurse should assess surgical incisions and respiratory status and give the scheduled antibiotic. (Option D) After NPO status is discontinued, the client should be offered fluids. This task can be delegated to unlicensed assistive personnel and is not the priority. Educational objective: Ventricular bigeminy in a client following a myocardial infarction indicates risk for developing ventricular tachycardia or ventricular fibrillation, both potentially life-threatening dysrhythmias. The nurse should assess the client's vital signs, electrolytes, and apical-radial pulse, and notify the health care provider.

The Charge Nurse on a Telemetry Unit Is Training a New