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Which of the following electrocardiography (ECG) findings would require immediate intervention?

A.

Arterial fibrillation with a rate of 88 beats per minute

B.

Ventricular fibrillation

C.

Sinus tachycardia with a rate of 105 beats per minute

D.

Normal sinus rhythm with a rate of 72 beats per minute

Answer and Explanation

The Correct Answer is B

A. Arterial fibrillation with a rate of 88 beats per minute: Atrial fibrillation with a controlled ventricular response of 88 beats per minute indicates hemodynamic stability. While this rhythm requires long-term management for stroke prevention, it is not an immediate life-threatening emergency. The patient can be monitored while awaiting pharmacological or electrical rate and rhythm control.

B. Ventricular fibrillation: This lethal arrhythmia represents disorganized electrical activity that results in the total loss of cardiac output. Without immediate defibrillation and cardiopulmonary resuscitation, the patient will progress to biological death within minutes. It is the highest clinical priority in electrocardiographic monitoring and requires an instant emergency response.

C. Sinus tachycardia with a rate of 105 beats per minute: A heart rate of 105 is a mild elevation that may be caused by pain, anxiety, fever, or dehydration. While it requires investigation into the underlying cause, it does not represent an immediate threat to life. It is a physiological response that usually resolves once the primary stressor is addressed.

D. Normal sinus rhythm with a rate of 72 beats per minute: This finding represents a healthy, physiologically normal cardiac rhythm. A rate of 72 falls perfectly within the standard adult range of 60 to 100 beats per minute. No nursing or medical intervention is required for this stable and expected monitoring result.


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Related Questions

Correct Answer is B

Explanation

A. Irregular heart beat with a rate of 86 bpm: While a rate of 86 is within the normal range, the persistence of an irregular rhythm indicates that the client has not returned to normal sinus rhythm. The primary goal of therapy includes rhythm stabilization or better rate control. An irregular rhythm still suggests a deviation from the previous day's successful conversion.

B. No edema noted in the bilateral extremities: The resolution of peripheral edema is a direct indicator that diuretic therapy and heart failure management have been effective. It demonstrates that the excess fluid has been successfully mobilized and excreted from the body. This finding confirms an improvement in the client's congestive state.

C. hypoactive bowel sounds in all 4 quadrants: Hypoactive bowel sounds were present at the start of the assessment and their persistence does not indicate a successful cardiovascular intervention. This finding is likely unrelated to the primary cardiac issue or may be a side effect of other medications. Improvement in cardiac output usually improves systemic perfusion, including the gut.

D. Decreased urine output: Successful treatment with a diuretic like furosemide should result in increased, not decreased, urine output. A decrease in output would suggest worsening renal perfusion or a lack of response to the medication. Effective management of heart failure aims to reduce fluid volume through diuresis.


Correct Answer is C

Explanation

A. Give 2 rescue breaths: In cardiac arrest due to V.Fib, the priority is circulation. High-quality chest compressions are initiated immediately to maintain perfusion until defibrillation can be performed. Rescue breaths are not the first step.

B. Start chest compressions: V.Fib is a lethal rhythm with no effective cardiac output. Immediate chest compressions are essential to circulate oxygenated blood to vital organs while preparing for defibrillation. This is the first action in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS).

C. Assess the client: While assessment is important, in the context of a witnessed rhythm strip showing V.Fib and an alarm, the nurse should assume cardiac arrest and act immediately. Delaying compressions to reassess wastes critical seconds.

D. Call a code blue/call 911: This is necessary, but it comes after starting chest compressions. The priority is to begin CPR without delay, then activate emergency response and prepare for defibrillation.

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