Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?
Initiate cardiopulmonary resuscitation (CPR).
Establish intravenous (IV) access.
Carry out immediate defibrillation.
Check the client’s latest electrolyte levels.
The Correct Answer is C
The correct answer is choice c. Carry out immediate defibrillation.
Choice A rationale:
Initiating cardiopulmonary resuscitation (CPR) is essential for a client who is unresponsive and without a pulse. However, in the presence of ventricular fibrillation, immediate defibrillation is the priority to restore a viable heart rhythm.
Choice B rationale:
Establishing intravenous (IV) access is important for administering medications during resuscitation. However, it is not the immediate priority when defibrillation is indicated.
Choice C rationale:
Immediate defibrillation is the priority action for a client with ventricular fibrillation who is unresponsive and without a pulse. Defibrillation can quickly restore a normal heart rhythm, which is critical in saving the client’s life.
Choice D rationale:
Checking the client’s latest electrolyte levels can provide valuable information for ongoing treatment but is not the immediate priority in an emergency situation where defibrillation is indicated. Immediate action to restore the heart rhythm is more critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Pulsus paradoxus, an exaggerated decrease in systolic blood pressure during inspiration, can be a sign of several conditions, including pericardial tamponade, constrictive pericarditis, and restrictive cardiomyopathy.
Choice B rationale
Exudate, a fluid with a high protein content that leaks out of blood vessels due to inflammation, is not typically associated with the symptoms described.
Choice C rationale
An aneurysm, a bulge or ballooning in a blood vessel, could potentially cause the symptoms described, but it is not the most concerning finding given the symptoms of edema, hepatomegaly, and muffled heart sounds.
Choice D rationale
Tamponade, a serious condition in which fluid or blood fills the pericardial sac, compressing the heart and preventing it from pumping effectively, could cause the symptoms described and would be the most concerning finding.
Correct Answer is C
Explanation
Choice A rationale
Adenosine (Adenocard) is a medication that can be used to treat supraventricular tachycardia, a type of abnormal heart rhythm. However, it is not typically used for atrial fibrillation.
Choice B rationale
Emergency cardioversion, where an electric shock is used to restore the heart’s normal rhythm, can be used in some cases of atrial fibrillation. However, if the atrial fibrillation has been present for more than 48 hours, there is a risk of blood clots, and anticoagulation for several weeks before the procedure may be needed.
Choice C rationale
Anticoagulant therapy is often used in patients with atrial fibrillation to reduce the risk of stroke. Atrial fibrillation can lead to blood pooling in the atria, increasing the risk of clot formation. These clots can then travel to the brain, causing a stroke.
Choice D rationale
Permanent pacemakers are sometimes used in atrial fibrillation to help regulate the heart’s rhythm. However, they are typically used when other treatments have failed or are contraindicated.
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