A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

What is the first action the nurse should take?

Choice A rationale
Education on the necessity of continuous antibiotic prophylaxis is crucial for patients who have just recovered from rheumatic fever. Rheumatic fever is an inflammatory disease that can develop as a complication of untreated or inadequately treated strep throat or scarlet fever.
Patients who have had rheumatic fever are at risk of getting it again if they have another strep infection. Continuous antibiotic prophylaxis can prevent recurrent infections and the development of rheumatic heart disease.
Choice B rationale
While anticoagulation therapy may be necessary for some patients with heart conditions, it is not typically the most important nursing action for a patient who has just recovered from rheumatic fever. Rheumatic fever can cause inflammation and damage to the heart valves, but it does not typically cause blood clots, which are the primary reason for anticoagulation therapy.
Choice C rationale
Adherence to standard infection control procedures is important for all patients, but it is not the most important nursing action for a patient who has just recovered from rheumatic fever. The primary concern for these patients is preventing recurrent strep infections, which can be achieved through continuous antibiotic prophylaxis.
Choice D rationale
While physical activity management may be part of the overall care plan for a patient who has just recovered from rheumatic fever, it is not typically the most important nursing action. The primary concern for these patients is preventing recurrent strep infections, which can be achieved through continuous antibiotic prophylaxis.

Choice A rationale
Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac. This procedure can be used to relieve pressure on the heart caused by a large pericardial effusion.
Choice B rationale
A pericardiectomy is a surgical procedure that removes part or all of the pericardium. It is typically used to treat constrictive pericarditis, not pericardial effusion.
Choice C rationale
Heart catheterization involves inserting a long, thin tube (catheter) into a blood vessel and guiding it to the heart. It is typically used to diagnose and treat certain cardiovascular conditions, not pericardial effusion.
Choice D rationale
A thoracotomy is a surgical procedure to gain access to the chest. It is typically used for lung, esophagus, or other chest organ operations, not pericardial effusion.