Rhythm Strip
A client comes to the emergency department (ED) complaining of a "racing heart and nervousness." The client's blood pressure is 106/60. The cardiac monitor displays the rhythm below. Which nursing action should be performed first?
Prepare the client for electrical cardioversion
Perform a carotid massage on the client.
Administer lidocaine 1mg/hour.
Ask the client if they drank a caffeinated beverage
The Correct Answer is B
A. Prepare the client for electrical cardioversion: Electrical cardioversion is reserved for unstable patients (e.g., hypotension, altered mental status, chest pain, or signs of shock). This client, while tachycardic, has a blood pressure of 106/60, which indicates relative stability. Cardioversion is not the first-line intervention in stable supraventricular tachycardia (SVT).
B. Perform a carotid massage on the client: Carotid sinus massage is a vagal maneuver used to slow conduction through the AV node and can terminate paroxysmal supraventricular tachycardia (PSVT). It is a non-invasive, first-line intervention for a stable patient with narrow-complex tachycardia, as shown on the ECG strip.
C. Administer lidocaine 1 mg/hour: Lidocaine is an antiarrhythmic used primarily to treat ventricular arrhythmias, such as ventricular tachycardia or fibrillation. It is not indicated for atrial or supraventricular tachycardias and would not address the underlying rhythm.
D. Ask the client if they drank a caffeinated beverage: While excessive caffeine intake can contribute to tachycardia, asking about caffeine use does not address the acute arrhythmia or guide immediate treatment. It may be part of history-taking but is not a priority intervention in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer amiodarone 200 mg IV push: Amiodarone is used for shockable rhythms like ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) that are refractory to defibrillation. The rhythm on the monitor is asystole, which is non-shockable, and amiodarone is not indicated here.
B. Defibrillate the client using 200 joules: Defibrillation is only appropriate for shockable rhythms such as VF or pulseless VT. Asystole is not shockable, and defibrillation in this rhythm would be ineffective and inappropriate.
C. CPR until the physician stops the code: The rhythm strip shows asystole, a flatline with no electrical activity. The priority intervention is to initiate and continue high-quality cardiopulmonary resuscitation (CPR) immediately and continue until the code is terminated by the physician. This is consistent with Advanced Cardiac Life Support (ACLS) guidelines.
D. Administer adenosine 12 mg IV push: Adenosine is used to terminate supraventricular tachycardia (SVT) and is not indicated in asystole or during cardiac arrest. It would have no effect in a rhythm with no electrical activity.
Correct Answer is B
Explanation
A. Cardiovert in the synchronized mode: Synchronized cardioversion is used for hemodynamically unstable but conscious patients with rhythms like atrial fibrillation or supraventricular tachycardia. It is not appropriate for a pulseless patient with ventricular fibrillation, as synchronization requires detectable R-waves.
B. Defibrillate immediately with a biphasic machine: The rhythm strip shows ventricular fibrillation (VF) a life-threatening arrhythmia characterized by chaotic, irregular waveform with no identifiable PQRST and no effective cardiac output. The patient is unresponsive and pulseless, making immediate defibrillation the priority action, as per Advanced Cardiac Life Support (ACLS) guidelines.
C. Take a full set of vital signs: The client is already unresponsive and pulseless, making a full set of vitals irrelevant at this moment. Immediate resuscitation efforts, including defibrillation and CPR, take priority.
D. Initiate cardiopulmonary resuscitation: While CPR is a critical part of the algorithm for pulseless rhythms, defibrillation is the first priority in ventricular fibrillation when a defibrillator is available and ready. CPR should be started immediately after the shock if no pulse returns.
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