A patient is having occasional premature ventricular contractions (PVCs). Which finding would require immediate nursing action?
1. There are no P waves in the PVCs.
2. The heart rate is irregular.
3. A PVC occurs at the top of the T wave.
4. Two PVCs occur in one minute.
3
Rationale 1: The P wave of a PVC is not present or is buried in the QRS. This is not the area of greatest concern.
Rationale 2: Because of the presence of these premature beats, the heart rate will be irregular. This is not the area of greatest concern.
Rationale 3: This is called "R-on-T" phenomenon and can herald ventricular tachycardia. This is a finding that calls for immediate nursing action.
Rationale 4: Frequent PVCs are of greater concern than occasional PVCs, but this is not the finding of most concern.
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