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?

A. Ensure all tubing connections are tightened: Tight tubing connections are critical in preventing accidental disconnection, which can result in rapid blood loss and air embolism. Arterial lines are under high pressure, so securing all connections is a top priority to ensure patient safety and maintain line integrity.

B. Apply a pressure dressing to the insertion site: A transparent occlusive dressing not a pressure dressing is used for arterial lines to allow for site visualization and reduce the risk of infection. A pressure dressing could obscure signs of bleeding or compromise the catheter’s position.

C. Perform an Allen's test: Allen’s test is performed prior to radial arterial line insertion to assess collateral circulation via the ulnar artery for preventing ischemic complications if the radial artery is compromised. Performing the test afterward does not prevent complications and is no longer relevant once the catheter is placed.

D. Obtain a portable x-ray to confirm placement: X-rays are used to confirm the placement of central lines, not peripheral arterial lines like the radial line. Arterial line placement is confirmed by waveform analysis and blood return, not imaging.

A. Dopamine and 50% non-rebreather mask: Dopamine is a vasopressor used in hypotension or shock, an inotropic agent used to improve cardiac output, not typically first-line for anxiety or respiratory distress. A non-rebreather mask may provide high oxygen levels but can be overwhelming and exacerbate anxiety if not well tolerated.

B. Nesiritide IV infusion and digoxin PO: Nesiritide is a vasodilator which may reduce preload and afterload in heart failure, and digoxin is a positive inotrope that can improve contractility, but neither offers rapid relief for anxiety and dyspnea. These medications have slower onset and are not used primarily for symptom control in acute distress.

C. Diazepam IV push and metoprolol IV: While diazepam may reduce anxiety, it can depress respiration, which is dangerous in decompensated heart failure with potential pulmonary edema. Metoprolol reduces heart rate and contractility and must be used cautiously in acute settings.

D. Morphine IV and oxygen 2 liters via nasal cannula: Morphine reduces preload, anxiety, and the sensation of breathlessness, making it ideal in acute decompensated heart failure. Low-flow oxygen improves oxygenation without overwhelming the patient. This combination directly targets both physiologic and psychological distress.