A nurse is caring for a client with chest pain who becomes unresponsive. The client is pulseless and apneic. The code team places the client on the monitor, which indicates ventricular fibrillation. What is the next priority action?

Amiodarone administration

Defibrillation

Epinephrine administration

Synchronized Cardioversion

Answer and Explanation

The Correct Answer is B

A. Amiodarone is an antiarrhythmic medication used after defibrillation and CPR in persistent ventricular fibrillation (VF) or ventricular tachycardia (VT). However, it is not the first priority.
B. Defibrillation is the immediate priority in a pulseless client with ventricular fibrillation. Early defibrillation increases the chances of survival. The shock should be delivered as soon as possible.
C. Epinephrine is given after the first defibrillation and CPR cycle, not before.
D. Synchronized cardioversion is inappropriate because it is used for unstable tachyarrhythmias with a pulse, not pulseless VF.

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Correct Answer is C

Explanation

A. Hypertensive crisis is not a direct complication of atrial fibrillation. It is typically caused by uncontrolled hypertension rather than arrhythmias.
B. Cardiogenic shock can occur in severe heart failure but is not a primary complication of atrial fibrillation.
C. Embolic cerebral vascular accident (stroke) is a major risk for clients with atrial fibrillation. The irregular atrial contractions allow blood to pool in the atria, increasing the risk of clot formation. If a clot dislodges, it can travel to the brain and cause a stroke.
D. Flash pulmonary edema is a complication of acute decompensated heart failure but is not directly caused by atrial fibrillation.

A. Murmur B. S3 and S4 C. Friction rub D. Click

Correct Answer is A

Explanation

A. A murmur is the expected heart sound in mitral valve regurgitation, caused by the backflow of blood into the left atrium during systole. It is typically a holosystolic murmur heard best at the apex of the heart.
B. S3 and S4 heart sounds may be heard in heart failure but are not specific for mitral regurgitation.
C. A friction rub is associated with pericarditis, not valvular disease.
D. A click is typically heard in mitral valve prolapse, not mitral regurgitation.

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A nurse is caring for a client with chest pain who becomes unresponsive. The client is pulseless and apneic. The code team places the client on the monitor, which indicates ventricular fibrillation. What is the next priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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