A client's abdominal aortic aneurysm (AAA) has ruptured. Which intervention is the highest priority for the nurse?

A. Call the health care provider for a change in cardiac drugs: Notifying the provider is important for ongoing management, but the rhythm shown in the image is ventricular fibrillation (VF), which is immediately life-threatening. Delaying action to call the provider risks the client’s survival.

B. Place the client in a sitting position and administer oxygen: Positioning and oxygen may support a stable client with mild symptoms, but VF causes ineffective cardiac output, so interventions that only support oxygenation are insufficient. Immediate resuscitative measures are required.

C. Call the rapid response team to come and assess the client: While the rapid response team can assist, VF requires immediate intervention—delaying defibrillation and CPR while waiting for others significantly reduces survival chances.

D. Call a code and initiate cardiopulmonary resuscitation: Ventricular fibrillation is a pulseless, life-threatening arrhythmia that requires immediate activation of a code and initiation of CPR, followed by defibrillation. Early chest compressions and defibrillation are critical to restoring cardiac output and preventing sudden cardiac death.

A. Obtain a STAT electrocardiogram (EKG).: An EKG evaluates cardiac rhythm and ongoing ischemic changes but does not assess neurological status. New disorientation during alteplase infusion raises concern for intracranial hemorrhage. Cardiac monitoring is important, but it does not address the immediate neurologic emergency suggested by acute mental status changes.

B. Call the primary health care provider immediately.: Alteplase is a fibrinolytic that increases the risk of bleeding, including intracranial hemorrhage. Sudden confusion and disorientation are early neurologic signs that may indicate cerebral bleeding. Immediate provider notification is critical so the infusion can be stopped and urgent neuroimaging, such as a CT scan, can be initiated to evaluate for hemorrhage.

C. Prepare the client for percutaneous cardiac intervention (PCI).: PCI is considered if thrombolytic therapy fails or if there is persistent ischemia. Disorientation is not an indication of failed reperfusion but rather a potential bleeding complication. Preparing for PCI would delay evaluation of a potentially life-threatening neurologic event.

D. Obtain STAT cardiac enzymes.: Cardiac enzymes help evaluate myocardial injury but are not useful in assessing acute neurologic deterioration. Elevated enzymes confirm myocardial infarction but do not explain sudden changes in mental status. The priority is evaluating for a hemorrhagic complication related to thrombolytic therapy.