A patient develops new atrial fibrillation with a ventricular rate of 160 per minute, chest discomfort, and a blood pressure of 84/50 mmHg. Which action is the priority?
Correct answer: A. Activate the emergency response system for urgent review
- A. Activate the emergency response system for urgent review
- B. Ask the patient to perform slow breathing exercises
- C. Offer oral fluids and repeat the blood pressure later
- D. Record the rhythm and continue the scheduled observations
Explanation
The dysrhythmia is accompanied by hypotension and chest discomfort, indicating haemodynamic instability. The nurse should obtain immediate emergency support rather than delay care for routine observation or oral treatment.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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