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.

Answer and Explanation

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.

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Correct Answer is ["A","D","E","F","H"]

Explanation

A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.

G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.

A. Bends from the waist to pick trash off the floor. B. Leans forward to pull a pan from a high shelf. C. Locks knees while preparing food on the counter. D. Widens stance while working near the sink. E. Brings a heavy can close to body before lifting.

Correct Answer is ["D","E"]

Explanation

A. Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B. Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C. Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

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A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

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