The nurse notes a widely bizarre pattern on the client's cardiac monitor. What is the nurse's priority action?
1. Call a code blue.
2. Check the client's pulse.
3. Immediately defibrillate the client.
4. Check the rhythm in a different lead.
Correct Answer: 2
Rationale 1: This is not the first thing that the nurse should do.
Rationale 2: The nurse should always remember to verify any changes on the cardiac monitor by assessing the client (in this case, checking the pulse). The cardiac monitor reports electrical activity that may not directly reflect the mechanical activity occurring in the heart.
Rationale 3: The nurse should not immediately defibrillate the client.
Rationale 4: The nurse should not check the rhythm in a different lead first.
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