The nurse observes the following rhythm of a client on the telemetry unit.
Which action should be completed first?
Report the findings and anticipate a medical prescription for amiodarone
Initiate a rapid response call and increase the monitor's sensitivity
Start compressions and prepare for defibrillation
Establish unresponsiveness and check the carotid pulse
The Correct Answer is D
A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypermagnesemia can cause bradycardia and hypotension, but it is less commonly associated with PVCs. This does not align with the lab results provided.
B. Hypocalcemia can cause arrhythmias, but it is not the most likely cause of PVCs in this case, considering other findings.
C. Hypokalemia (low potassium) is a known cause of PVCs. The patient's potassium level is 2.8 mEq/L, which is significantly low and most likely contributing to the PVCs.
D. Although hyperglycemia can affect cardiac function, it is less commonly linked to PVCs compared to electrolyte imbalances, such as hypokalemia.
Correct Answer is D
Explanation
A. This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B. This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C. This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D. This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.
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