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 D

Explanation

A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.

A. Oxygen saturation 98% on room air B. Urine output 20 mL in the last hour C. Basilar crackles D. Heart rate 72 beats/minute E. Respiratory rate 26 breaths/minute F. Blood pressure 126/76 mm Hg G. Electrocardiogram Tall T wave and widened QRS complex H. Temperature 98.9° F (37.1° C) orally

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.

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

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Naxlex Comprehensive Predictor Exams

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