A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

What is the first action the nurse should take?

Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice B rationale
Cardioverting the client with a biphasic defibrillator is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice C rationale
The first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern is to assess the patient’s airway, breathing, and circulation.
Choice D rationale
Administering an amiodarone bolus followed by a drip is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.

Choice A rationale
Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac. This procedure can be used to relieve pressure on the heart caused by a large pericardial effusion.
Choice B rationale
A pericardiectomy is a surgical procedure that removes part or all of the pericardium. It is typically used to treat constrictive pericarditis, not pericardial effusion.
Choice C rationale
Heart catheterization involves inserting a long, thin tube (catheter) into a blood vessel and guiding it to the heart. It is typically used to diagnose and treat certain cardiovascular conditions, not pericardial effusion.
Choice D rationale
A thoracotomy is a surgical procedure to gain access to the chest. It is typically used for lung, esophagus, or other chest organ operations, not pericardial effusion.