The nurse is caring for a client in the telemetry unit and notices the rhythm below. The client is unresponsive and pulseless. After calling for assistance, what should be the nurse's next action?

Cardiovert in the synchronized mode.

Defibrillate immediately with a biphasic machine.

Take a full set of vital signs.

Initiate cardiopulmonary resuscitation.

Answer and Explanation

The Correct Answer is B

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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Correct Answer is A

Explanation

A. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and an unmeasurable PR interval. The ventricular rate can vary (in this case, 92/min), and QRS duration is usually normal. These findings match the classic ECG criteria for atrial fibrillation.

B. Sinus bradycardia: Sinus bradycardia features a regular rhythm, visible P waves before each QRS, and a rate below 60 bpm. The client's rate is 92 and the rhythm is irregular, ruling out this option.

C. Supraventricular tachycardia: SVT typically presents with a regular, rapid rhythm, often over 150 bpm, and P waves may be hidden in the preceding T wave. The client’s rate is 92 with an irregular rhythm, which does not fit SVT.

D. First-degree heart block: First-degree AV block is defined by a prolonged PR interval (>0.20 seconds) with otherwise normal sinus rhythm. In this case, the PR interval is unmeasurable and the rhythm is irregular, making this diagnosis unlikely.

A. Pulmonic B. Aortic C. Tricuspid D. Mitral

Correct Answer is A

Explanation

A. Pulmonic: The pulmonic valve is best auscultated at the second left intercostal space along the left sternal border. A murmur heard in this location is most likely associated with pulmonic valve abnormalities such as pulmonary stenosis or pulmonary regurgitation.

B. Aortic: The aortic valve is auscultated at the second right intercostal space at the right sternal border. A murmur at this site may indicate aortic stenosis or regurgitation, but not when heard on the left side as in this scenario.

C. Tricuspid: Tricuspid valve murmurs are typically heard best at the lower left sternal border, around the fourth or fifth intercostal space. This location is more inferior than where the nurse auscultated the murmur in the current assessment.

D. Mitral: The mitral valve is best heard at the fifth intercostal space at the midclavicular line (the cardiac apex). Murmurs related to mitral stenosis or regurgitation would not typically be heard at the second intercostal space near the sternum.

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The nurse is caring for a client in the telemetry unit and notices the rhythm below. The client is unresponsive and pulseless. After calling for assistance, what should be the nurse's next action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is assessing a new admission and hears a murmur at the second left intercostal space along the left sternal border. The nurse anticipates the client has a murmur of which valve?

Correct Answer is A

Explanation

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