The nurse finds the client to be in ventricular tachycardia and pulseless. What is the nurse's best first action?
Initiate CPR.
Administer oxygen
Administer an antidysrhythmic agent
Instruct the client to inhale deeply and cough
The Correct Answer is A
A. Initiate CPR: Pulseless ventricular tachycardia is a life-threatening cardiac arrest rhythm. Immediate initiation of high-quality cardiopulmonary resuscitation (CPR) is the highest priority to maintain circulation and perfusion to vital organs. Early CPR improves the likelihood of return of spontaneous circulation and survival until defibrillation and advanced interventions can be performed.
B. Administer oxygen: While oxygen is important, providing supplemental oxygen does not replace the need for immediate CPR in a pulseless patient. Oxygen delivery becomes effective only if circulation is maintained, which is why CPR takes precedence.
C. Administer an antidysrhythmic agent: Antidysrhythmic drugs such as amiodarone may be used during pulseless V-Tach according to ACLS protocols, but administration is secondary to initiating CPR and defibrillation. Delaying CPR to give medication would reduce chances of survival.
D. Instruct the client to inhale deeply and cough: Cough CPR or the Valsalva maneuver is ineffective in true cardiac arrest. A pulseless, unconscious patient cannot follow commands, and these interventions do not provide circulation or address the life-threatening arrhythmia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Attach defibrillator pads to the client: Attaching defibrillator pads is essential for rhythm analysis and shock delivery in cardiac arrest, but it is not the very first step. Immediate assessment of responsiveness and circulation must precede defibrillation to determine the appropriate intervention.
B. Deliver two breaths: Providing rescue breaths is part of CPR, but it should only be initiated after confirming that the client is unresponsive and pulseless. Delivering breaths before checking for a pulse could delay recognition of a perfusing rhythm.
C. Check for a carotid pulse: Assessing the carotid pulse is the first critical action after finding an unresponsive client. Determining the presence or absence of circulation guides whether to initiate chest compressions, call for advanced support, or begin other life-saving interventions. This step ensures appropriate prioritization of resuscitative measures.
D. Begin chest compressions: Chest compressions are essential in cardiac arrest, but they should be started only after confirming that the client is pulseless. Immediate compressions without pulse assessment could lead to unnecessary trauma in a patient who may still have circulation.
Correct Answer is C
Explanation
Rhythm: Absent
Rate: Absent
P wave: Discernible
PR interval: Absent
QRS: Absent
Rhythm interpretation: Asystole
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