A nurse cares for a client who manifests Ventricular Tachycardia on a cardiac monitor. Which action should the nurse take first?
Prepare the defibrillator for potential use.
Call the physician for further instructions.
Assess the client's airway, breathing, and circulation.
Administer antiarrhythmic medication.
The Correct Answer is C
Rationale:
A. While defibrillation may be necessary, it should not be the first action. Immediate assessment determines whether the client is pulseless or unstable, which guides the appropriate intervention.
B. Delaying assessment to contact the provider could waste critical time, especially in life-threatening arrhythmias like VT. Nurses must act immediately according to the patient’s condition and protocols.
C. The first action in any suspected life-threatening arrhythmia is to assess the patient’s ABCs. This assessment determines hemodynamic stability and guides whether to perform CPR, defibrillation, or prepare for cardioversion, prioritizing patient safety.
D. Antiarrhythmic drugs may be indicated after assessment and determination of stability, but they are not the initial intervention. Immediate evaluation of ABCs is required to prevent deterioration.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. This is a long-term treatment for recurrent VT or other arrhythmias. It is not an immediate intervention for acute, unstable VT.
B. Cardiopulmonary resuscitation is performed only if the client is pulseless and unresponsive. While CPR may be necessary in cardiac arrest, it is not the first-line intervention for VT with a pulse.
C. Synchronized cardioversion is used for hemodynamically stable VT with a pulse, but the term “elective” implies a planned procedure, not emergency management.
D. For pulseless VT or VT causing severe instability (e.g., hypotension, altered mental status), defibrillation is the immediate lifesaving intervention. It delivers an unsynchronized shock to restore normal cardiac rhythm.
Correct Answer is C
Explanation
Rationale:
A. While defibrillation may be necessary, it should not be the first action. Immediate assessment determines whether the client is pulseless or unstable, which guides the appropriate intervention.
B. Delaying assessment to contact the provider could waste critical time, especially in life-threatening arrhythmias like VT. Nurses must act immediately according to the patient’s condition and protocols.
C. The first action in any suspected life-threatening arrhythmia is to assess the patient’s ABCs. This assessment determines hemodynamic stability and guides whether to perform CPR, defibrillation, or prepare for cardioversion, prioritizing patient safety.
D. Antiarrhythmic drugs may be indicated after assessment and determination of stability, but they are not the initial intervention. Immediate evaluation of ABCs is required to prevent deterioration.
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