The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below:
After calling for assistance and a defibrillator, which action should the nurse take next?
a.
Perform a pericardial thump.
b.
Initiate cardiopulmonary resuscitation (CPR).
c.
Start an 18-gauge intravenous line.
d.
Ask the client's family about code status.
ANS: B
The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.
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