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 B
Explanation
Shock is a state of inadequate tissue perfusion, resulting in compromised oxygen and nutrient delivery to cells and impaired cellular metabolism. Regardless of the specific cause or type of shock (e.g., hypovolemic, cardiogenic, distributive), the underlying problem is the failure to supply sufficient oxygen and nutrients to the body's tissues. This inadequate tissue perfusion can lead to cellular dysfunction, organ failure, and ultimately, life-threatening consequences.
A. Inefficient metabolism resulting from inadequate nutrition in (option A) is incorrect because While inadequate nutrition can contribute to the overall health status and resilience of an individual, it is not the central mechanism underlying all shock states.
C. Vasoconstriction and reflexive vasodilation due to circulating mediators in (option C) is incorrect because Vasoconstriction and vasodilation are physiological responses that can occur in various types of shock, but they are not the fundamental common denominator. Inadequate tissue perfusion remains the core issue.
D. Hypovolemia resulting from blood loss in (option D) is incorrect because Hypovolemia, which refers to decreased blood volume, is one potential cause of shock, specifically hypovolemic shock. However, other types of shock, such as cardiogenic or distributive shock, may not be primarily characterized by hypovolemia.
Therefore, the common denominator of all shock states is inadequate tissue perfusion, resulting in impaired cellular metabolism.
Correct Answer is B
Explanation
Cool, clammy skin, tachycardia, and hypotension are signs of shock, indicating inadequate tissue perfusion and oxygenation. The immediate priority is to ensure adequate oxygen delivery to the tissues. Providing oxygen at 100% via a non-rebreather mask helps increase the patient's oxygen saturation and improve tissue oxygenation.
While all the options mentioned are important in the management of a patient in shock, oxygenation takes priority as it directly addresses compromised tissue perfusion and oxygenation.
A. Inserting two large-bore IV catheters in (option A) is incorrect because: Establishing intravenous access is crucial for fluid resuscitation and administration of medications, but it can be done after ensuring adequate oxygenation.
C. Drawing blood to type and crossmatch for transfusions in (option C) is incorrect because Blood typing and crossmatching are important for potential blood transfusions but should not be the first action in this critical situation.
D. Initiating continuous electrocardiogram (ECG) monitoring in (option D) is incorrect because Continuous ECG monitoring is important for assessing cardiac rhythm and detecting any dysrhythmias, but ensuring oxygenation should be the initial priority.
Therefore, in a patient presenting with cool, clammy skin, tachycardia, and hypotension, the nurse should first provide oxygen at 100% via a non-rebreather mask to address inadequate tissue perfusion and oxygenation.
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