During an endocrine assessment, the nurse notes that the patient's heart rate is sustained at 160 beats per minute. The patient reports nervousness but has no loss of consciousness or reduced mentation. What nursing intervention is priority?

Question

1. Ask how long the patient's heart has been beating so fast.
2. Note the findings in the patient's medical record.
3. Notify the health care provider immediately.
4. Have the patient ambulate around the room and reassess.

Answer 1

3
Rationale 1: While onset of symptomology is always important, this is not the priority nursing intervention.
Rationale 2: Documentation is important but is not the priority nursing intervention.
Rationale 3: This heart rate is dangerous and the patient may decompensate rapidly. Pharmacologic intervention is probably indicated until more definitive treatment can be given.
Rationale 4: The patient's heart rate will not decrease with the added physiologic stress of walking.