A nurse is working on telemetry unit when an alarm sounds on the cardiac monitor The rhythm below is noted. What should the nurse do?

Call the physician

Administer oxygen

Initiate cardiopulmonary resuscitation (CPR)

Give a dose of epinephrine

Answer and Explanation

The Correct Answer is C

A. Call the physician: While notifying the physician is important, it is not the immediate priority in a life-threatening situation like ventricular fibrillation.

B. Administer oxygen: Administering oxygen is helpful, but the immediate priority in ventricular fibrillation is to initiate life-saving measures.

C. Initiate cardiopulmonary resuscitation (CPR): Ventricular fibrillation is a life-threatening emergency, and initiating CPR immediately is crucial to restore circulation and improve chances of survival.

D. Give a dose of epinephrine: Epinephrine is part of the advanced cardiac life support (ACLS) protocol, but it should be administered after initiating CPR and defibrillation.

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Correct Answer is B

Explanation

A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.

B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.

C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.

D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.

A. A patient with second-degree atrioventricular (AV) block, type 1. rate 60, who is dizzy when ambulating B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due.

Correct Answer is D

Explanation

A. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating. While dizziness may be a concern, second-degree AV block type 1 (Wenckebach) typically resolves without immediate intervention.

B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago. This patient is stable, and recovery from cardioversion typically involves monitoring, but the patient does not require immediate intervention.

C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due. The patient is stable, and the dose of warfarin can be administered after assessing the patient’s overall condition, making it a lower priority.

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due: The patient whose ICD fired twice is at high risk for life-threatening arrhythmias, and this situation requires immediate evaluation and intervention. The nurse should assess the patient first, and the dose of amiodarone may be administered to manage any underlying arrhythmias.

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A nurse is working on telemetry unit when an alarm sounds on the cardiac monitor The rhythm below is noted. What should the nurse do?

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