Which is the priority intervention for the unconscious client in ventricular fibrillation Quizlet
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Terms in this set (18)You are the nurse working on the telemetry unit and you have finally gotten to sit down to work on some charting. Suddenly the heart monitors at the station start beeping. Patient in room 18 is showing this rhythm on the monitor. The medical team advances together into the room and finds them unconscious. What is priority action by
the nurse? Answer: D. A pulse would be assessed for first. Then the patient will be defibrillized and chest compressions will begin immediately. The nurse sees the following rhythm on the monitor. Which of the following lab values does the nurse identify as being most
likely to have caused this dysrhythmia? Answer: C. Anemia can contribute to sinus tachycardia. The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses consciousness. The patient is defibrillated, and the rate returns as the following. What should the nurse do first? Answer: A. Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not initiated. The client may need to be shocked again, but chest compressions must begin first. A patient with cardiomyopathy has been given an ICD. Which of the following medications would the nurse expect to see in the MAR for this patient? Answer: B. Antiarrhythmic medications are prescribed with the use of an ICD in order to prevent the tachycardic (or other deadly arrhythmia) from occurring in the first place. This makes sure that the ICD is used only when absolutely necessary. The patient with a history of hypertension and diabetes has the following rhythm strip. The patient's vitals are
as follows: BP 145/89, HR 90, SpO2 95%, RR 19. Which of the following does the nurse expect to do at this time? Answer: B. Atrial flutter places the client at high risk for development of clot formation in the atria. Because the client is stable at this time, cardioversion or adenosine would not be performed at this time. Before cardioversion can occur in a patient, anticoagulant therapy should be begun at least 48 hours beforehand if possible. The nurse is preparing to administer adenosine to the patient with the following rhythm which is symptomatic. What should the nurse plan on having in the patient room? Answer: A, B, and D. Adenosine is administered as a very quick IV push. The physician must be present in the room and the crash cart must be on hand. An ekg monitor should be in the room to monitor the effectiveness of the medication. The nurse has just administered adenosine via IV push and sees the following rhythm on the monitor. What is the nurse's priority intervention? Answer: B. This finding would be expected upon administration of adenosine. The rhythm should then begin again in some other rhythm, hopefully normal sinus rhythm. It would be important to document the exact time of this change and continue to monitor the change back to NSR. If this change does not occur, or if another rhythm is produced, appropriate action would then be taken based on the result. You, the nurse, note the following rhythm on the EKG monitor for a patient named billy. What is the first thing the nurse should do? Answer: B. With SVT (Supraventricular tachycardia), the first thing to do would be to instruct the pt. to perform the Valsalva maneuver by bearing down. A group of nursing students are discussing atrial flutter. These students recognize that which of the following are seen with atrial flutter? Select all that apply: Answer(s): 2, 3 The ATRIAL rate is 220-300 bpm. Ventricular is about 75-150. The rhythm is regular, with the P wave appearing as little flutter or a "saw tooth pattern". The PR interval is not measurable r/t this saw-tooth P wave. The QRS is normal. A nursing student is aware that which of the following is the treatment for unstable atrial flutter? Answer: 2) Cardioversion is used if the patient is unstable. Anticoagulants are used if the arrhythmia has stuck around for 48 hr +. Adenosine may be used with a narrow QRS and regular RR interval. I made up Altemose. A nurse working on a CVT unit receives report from day shift. After receiving report, which patient should the
nurse see first? Answer: 2) Patients with a-fib are at risk for pulmonary and systemic emboli, and new onset of confusion may indicate a stroke in this patient. Patients with atrial flutter may feel more tired some days than others. A nurse on a CVT unit views the monitor and sees the patient in room 452 has just begun having occasional PVCs. Which action should the nurse take first? Answer: 1) Although electrolytes are likely the culprit, the nurse first needs to first assess the patient. Then, the nurse should look in the patient's chart and evaluate or request an order for electrolyte levels. This may eventually need to be documented, but the nurse can be held liable for neglect if he/she does not assess the patient first. The physician may or may not need to be contacted. Which of the
following does the nursing student realize is the treatment for a stable patient presenting with QRS intervals above 0.12 seconds with a regular rhythm and a rate of 100-250 bpm? Answer: 3) This is describing ventricular tachycardia (QRS is a giveaway), and the treatment for a stable patient is Amiodarone or cardioversion. If the patient were unstable, we'd go ahead and defibrillate. The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? a) Administer atropine 0.5 mg Answer: d) We cannot defibrillate asystole. A A group of nursing students are studying AV blocks and ask their instructor, "what causes a first-degree block?" The nursing instructor responds that which of the following can cause a first-degree block: Select all that apply Answer(s): 2, 3, 4, 5 A 26-year-old client with atrial fibrillation that has not responded to medication therapy has arrived at the hospital for an elective cardioversion. Which of the following patient statements most concerns the nurse? Answer: 3 Patients with atrial fibrillation are at incredibly high risk for clots, even with anticoagulation therapy. Shortness of breath could indicate a PE, and this should be immediately investigated by the nurse. The patient should be NPO for at least 4 hr. prior to the procedure related to anesthesia use, but this is not as urgent of a concern. The patient should also withhold Digoxin therapy for 48 hours to ensure that, once cardioverted, NSR returns. Which of the following signs and symptoms indicate pacemaker failure? Answer: B The nurse is providing discharge teaching to the client who has just received a pacemaker. Which of the following should the nurse include in the plan of care? SATA: Answer: A, C, D, and E. A cellphone should not be used near the pacemaker and it's best to keep the phone about half a foot away from the pacemaker. It is not necessary for the client to avoid using a microwave or other electrical devices. However, magnets should be kept away from the device. In order to prevent disruption of the leads after implantation (the most common complication), patients are often taught to limit activity on the affected side for awhile after implantation. Pulses are a good indicator of whether the pacemaker is supplying the body with enough cardiac output. Sets with similar termsreview chp2676 terms bobbie_bloydstout review chp2676 terms kgboswell Med-Surg Evolve Questions ch. 32-3865 terms katwoman201 MedSurg Final Exam Practice Tests56 terms chrismason0513 Sets found in the same folderDysrhythmia NCLEX Questions12 terms beccasn Dysrhythmias Misc nclex33 terms anthony_t_caraballo 253 - Cardiovascular NCLEX Questions112 terms deannaallen EKG and Dysrhythmias NCLEX18 terms lmr2333 Other sets by this creatorNCLEX STUDY 275 terms Rebekah_Newton6 EKG NCLEX Questions7 terms Rebekah_Newton6 Mental Health Exam 134 terms Rebekah_Newton6 Peds Final626 terms Rebekah_Newton6 Other Quizlet setsNeuroscience Unit 1 Exam222 terms sydney_seese1 module 8 exam 3257 terms c_engelking Lab 13: Intro to Motor Systems35 terms aya_ahmad2 ortho hip tophat50 terms mollyschulteis5 Related questionsQUESTION What does a cervical collar do? 12 answers QUESTION the elbow flexion test is positive when.. 7 answers QUESTION What are the levels and sources of normal daily electrolyte loss? 15 answers QUESTION what is meant by somatic/embryological referred pain? 15 answers Which is the priority intervention for the unconscious client in ventricular fibrillation?Cardiopulmonary resuscitation (CPR).
First call 911 or your local emergency number. Then start CPR by pushing hard and fast on the person's chest — about 100 to 120 compressions a minute. Let the chest rise completely between compressions.
What is the most effective initial intervention for ventricular fibrillation?Ventricular Fibrillation/Pulseless Ventricular Tachycardia. The most critical interventions during the first minutes of VF or pulseless VT are immediate bystander CPR (Box 1) with minimal interruption in chest compressions and defibrillation as soon as it can be accomplished (Class I).
What is the immediate treatment for ventricular fibrillation?Ventricular fibrillation is an emergency that requires immediate medical attention. It's the most frequent cause of sudden cardiac death. Emergency treatment for ventricular fibrillation includes cardiopulmonary resuscitation (CPR) and shocks to the heart with a device called an automated external defibrillator (AED).
What is the immediate priority for a patient in ventricular fibrillation VF or pulseless ventricular tachycardia VT )?Pulseless VT is a medical emergency that requires immediate defibrillation. The energy of 150-200 J on biphasic and 360 J on monophasic defibrillator should be used. Delaying defibrillation of pulseless VT dramatically decreases the survival rate.
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