A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?
Defibrillate with one shock.
Prepare for external pacing.
Administer atropine IV.
Give a dose of amiodarone IV.
The Correct Answer is A
A. Defibrillation is the immediate treatment of choice for ventricular fibrillation to restore a normal heart rhythm. It delivers an electric shock to the heart, which can stop the abnormal rhythm and allow the heart to resume its normal rhythm.
B. External pacing is not effective for ventricular fibrillation as it requires an organized electrical activity to pace.
C. Atropine is used for bradycardia, not ventricular fibrillation.
D. Amiodarone is used to stabilize the heart rhythm after defibrillation but is not the immediate treatment for VF.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A toileting schedule is unnecessary for an anuric client as they do not produce urine.
B. Anemia is a common complication of chronic kidney disease due to reduced erythropoietin production, so monitoring for signs of anemia is important.
C. High potassium foods should be avoided as impaired kidney function can lead to hyperkalemia.
D. While perineal skin care is important, it is not as critical as monitoring for anemia in this context.
Correct Answer is ["A","C","E","G","H"]
Explanation
A. Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B. Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.
C. A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D. Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E. Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F. Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G. Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H. Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I. A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.
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