Final answer:
In the event of a sudden onset of an abnormal cardiac rhythm after myocardial infarction, the priority of the nurse depends on the patient's condition. If the patient is unresponsive, immediate CPR should be initiated. If the patient is responsive, administration of nitroglycerin and contacting the physician are recommended, alongside monitoring blood pressure.
Step-by-step explanation:
When monitoring a patient via cardiac telemetry, the nurse must be prepared for any abrupt changes in the patient's cardiac rhythm that could indicate a life-threatening situation. If the patient has a sudden onset of an abnormal rhythm after a myocardial infarction (MI), the nurse's immediate action should be dictated by the patient's clinical signs and symptoms. It's important for nursing staff to be trained in interpreting telemetry monitoring to accurately assess the situation.
If the client becomes unresponsive or shows signs of sudden cardiac arrest, such as no breathing or no pulse, initiating cardiopulmonary resuscitation (CPR) is the priority to maintain blood circulation and oxygen delivery to vital organs. CPR technique involves chest compressions of at least 5 cm deep at a rate of 100 compressions per minute, which aligns with CPR standards.
For a responsive patient with an altered but non-life-threatening rhythm, other measures such as administrating nitroglycerin could be considered if appropriate for their condition. Nitroglycerin facilitates vasodilation, providing relief from chest pain associated with angina or after a heart attack. Additionally, it is crucial to contact the physician immediately for further instructions, given the seriousness of the patient's condition.
Monitoring blood pressure is also important, as significant changes in blood pressure can indicate the severity of the cardiac event. However, taking the client's blood pressure should not delay more pressing interventions like CPR in an emergency where the patient is unresponsive.