A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below:
Which action should the nurse take first?
a.
Assess airway, breathing, and level of consciousness.
b.
Administer an amiodarone bolus followed by a drip.
c.
Cardiovert the client with a biphasic defibrillator.
d.
Begin cardiopulmonary resuscitation (CPR).
ANS: A
Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.
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