At the beginning of your shift, you start your rounds on your patients. Upon entering this patient’s room, you observe that the cardiac monitor shows sinus tachycardia, is apneic and no pulses are palpable by the nurse.
What is the first action that the nurse should take?
Administer the prescribed Beta-Blocker
Prepare for Cardioversion per hospital protocol.
Give 100% oxygen per non-rebreather mask.
Start CPR
The Correct Answer is D
The absence of palpable pulses suggests a lack of effective cardiac output, and the patient is in cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is crucial to maintain circulation and provide oxygenation to vital organs.
CPR consists of chest compressions and rescue breaths to circulate oxygenated blood to the brain and other vital organs. It is the primary intervention in cardiac arrest to provide temporary life support until advanced cardiac life support (ACLS) measures, such as defibrillation or medication administration, can be initiated.
A. Administering the prescribed Beta-Blocker in (option A) is incorrect because Administering a beta-blocker is not the initial action in a patient who is in cardiac arrest and requires immediate resuscitation.
B. Prepare for Cardioversion per hospital protocol (option B) is incorrect because Cardioversion, which is the delivery of an electric shock to the heart, may be considered in certain situations like unstable ventricular tachycardia or certain supraventricular tachycardias. However, in the given scenario, the patient is unresponsive and has no pulses, indicating cardiac arrest where CPR takes precedence over cardioversion.
C. Give 100% oxygen per non-rebreather mask in (option C) is incorrect because: While oxygenation is important, it should not delay or replace the initiation of CPR, which is the immediate priority in a patient without palpable pulses.
Therefore, the first action that the nurse should take in this scenario is to start CPR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. In this critical situation, one of the initial priorities is to restore intravascular volume and improve tissue perfusion. Initiation of an intravenous line allows for the administration of fluids and other necessary medications to support the patient's hemodynamic stability.
While the other interventions mentioned are also important components of septic shock management, the immediate priority is to address hypotension and tissue hypoperfusion through fluid resuscitation:
A. Obtaining wound and blood cultures in (option A) is incorrect because: Cultures are important to identify the source and causative organisms of the infection. However, fluid resuscitation should take priority over obtaining cultures, as it is necessary to stabilize the patient's hemodynamics.
B. Removing or controlling potentially infected sources in (option B) is incorrect because: Identifying and controlling the source of infection is crucial in septic shock management to prevent further progression. However, initiating fluid resuscitation is more time-sensitive and should be prioritized.
D. Drawing blood for hematology and chemistry studies in (option D) is incorrect because Laboratory studies are important for evaluating organ function and guiding treatment. However, the immediate focus should be on fluid resuscitation to address the underlying hypoperfusion and stabilize the patient's condition.
Therefore, the intervention considered a priority when treating a patient who presents with septic shock is the initiation of an intravenous line and fluid administration to restore intravascular volume and improve tissue perfusion.
Correct Answer is D
Explanation
When the low-pressure alarm sounds, it indicates that the pressure being detected by the arterial line is below the set threshold. This could be due to a variety of reasons, such as a loose connection, air bubbles, or a shift in the zero-reference point.
Rezeroing the monitoring equipment involves recalibrating or resetting the baseline reference point for the arterial pressure waveform. This ensures accurate measurement and monitoring of the patient's arterial pressure.
A. Checking the right hand for a rash in (option A) is incorrect because While assessing the patient for any skin changes or rashes is important, it is not the first action to take in response to a low-pressure alarm.
B. Assessing the waveform for under-dampening in (option B) is incorrect because Assessing the waveform characteristics is important in arterial line monitoring, but it may not be the initial action when the low-pressure alarm sounds. Rezeroing the equipment should be performed before assessing waveform characteristics.
C. Assessing for cardiac dysrhythmias in (option C) is incorrect because Assessing for dysrhythmias is an important aspect of patient care, but it may not be directly related to the low-pressure alarm from the arterial line. Rezeroing the monitoring equipment takes precedence.
Therefore, when the low-pressure alarm sounds for a patient with an arterial line, the nurse should first re-zero the monitoring equipment to ensure accurate measurement of arterial pressure.
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