A nurse is caring for a client with the six second telemetry strip below. The nurse anticipates the emergency response team will administer which medication?

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. Perform range of motion (ROM) exercises: While early mobility is important, ROM exercises involving the affected arm should be limited initially to prevent disruption of the radial artery access site. Encouraging movement too soon could increase bleeding or hematoma formation.

B. Assess the insertion site: Frequent assessment of the radial artery access site is essential after a TAVR via the radial approach. The nurse monitors for bleeding, hematoma, swelling, discoloration, or compromised distal circulation, ensuring early detection and management of vascular complications.

C. Maintain NPO status for 2-6 hours: NPO status is typically required for procedures involving sedation, anesthesia, or femoral access to prevent aspiration. After a radial approach TAVR, the client may resume oral intake sooner, and prolonged NPO is usually unnecessary.

D. Log roll the client to use the bedpan: Log-rolling is used to protect the spine or after certain surgeries. For a radial artery access site, rolling the client is not indicated and does not reduce risk at the wrist. Care should focus on protecting the arm and monitoring vascular integrity rather than body positioning maneuvers.