The nurse recognizes third-degree AV block on a patient's EKG strip. What does the nurse expect the treatment to be?

Choice A rationale

Ventricular tachycardia is characterized by a rapid, wide QRS complex rhythm originating from the ventricles. While it can occur without a pulse, the prompt describes a normal sinus rhythm on the monitor. Ventricular tachycardia would show a distinct lack of P waves and a heart rate typically above 100 beats per minute. Because the monitor shows a normal pattern but the patient is unresponsive with no pulse, this diagnosis is scientifically incorrect.

Choice B rationale

Pulseless electrical activity occurs when the heart's electrical conduction system functions in a relatively normal organized fashion, but the myocardium fails to produce a mechanical contraction or sufficient stroke volume to generate a palpable pulse. This results in an organized rhythm like sinus rhythm on the ECG monitor despite the clinical state of cardiac arrest. It requires immediate CPR and identification of reversible causes such as hypovolemia, hypoxia, or electrolytes imbalances to restore mechanical function.

Choice C rationale

Sudden cardiac death is a broad clinical term used to describe an unexpected natural death due to cardiac causes, usually within one hour of symptom onset. While the patient in the scenario is in cardiac arrest, the term does not describe the specific cardiac rhythm observed on the monitor. It is a clinical outcome rather than a rhythmic classification. The nurse must identify the specific rhythm to guide the advanced cardiovascular life support interventions required.

Choice D rationale

Premature ventricular contractions are single ectopic beats that interrupt the regular underlying rhythm and are usually followed by a compensatory pause. They do not typically cause a complete loss of pulse or unresponsiveness unless they occur so frequently that they transition into a more lethal arrhythmia. A rhythm that looks like normal sinus rhythm but lacks a pulse is a systemic failure of mechanical output, not a minor electrical irritability issue like PVCs.

Choice D rationale

Assessing the patient's respiratory status is the priority when tube displacement is suspected. Moving from 21-cm to 24-cm indicates the tube has slipped deeper, likely into the right mainstem bronchus. This displacement prevents ventilation of the left lung, leading to hypoxia, anxiety, and restlessness. Auscultating lung sounds allows the nurse to confirm absent or diminished breath sounds on the left side, providing immediate clinical evidence of the malposition before proceeding with other interventions or notifications.

Choice A rationale

While the healthcare provider must be informed of a change in tube position and the patient's deteriorating status, this is not the first action. The nurse must first perform a rapid physical assessment to determine the severity of the situation and the immediate impact on gas exchange. Clinical data, such as absent breath sounds or falling oxygen saturation, must be gathered first to provide a concise and accurate report to the provider for further orders or repositioning.

Choice B rationale

Manual ventilation with 100 percent oxygen is indicated if the patient is in severe respiratory distress or if the tube is completely dislodged. However, since the tube has moved deeper into the airway, bagging the patient without confirming the position could worsen complications or provide inadequate ventilation to the occluded lung. The nurse should first assess lung sounds to identify if the tube is in the bronchus, as the tube might simply need to be pulled back slightly.

Choice C rationale

Reassuring the patient is a supportive measure but is not the priority when there is an objective sign of airway compromise and physiological distress. The patient's anxiety and restlessness are clinical symptoms of hypoxia caused by the displacement of the endotracheal tube to the 24-cm mark. Addressing the underlying physiological cause by assessing the airway and ensuring adequate ventilation is the most effective way to reduce the patient's anxiety and ensure their safety and stability.