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1. Question
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
Correct
Option C is the correct answer:
Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.
Incorrect
Option C is the correct answer:
Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.
Premature ventricular contractions:
Description
Early ventricular complexes result from increased irritability of the ventricles.
PVCs frequently occur in repetitive patterns such as bigeminy, trigeminy, and quadrigeminy.
The QRS complexes may be unifocal or multifocal.
Interventions
Notify the physician if PVCs occur.
Identify the cause and treat based on the cause.
Evaluate oxygen saturation to assess for hypoxemia, which can cause PVCs.
Administer oxygen as prescribed.
Evaluate electrolytes, particularly the potassium level, because hypokalemia can cause PVCs.
