Prepare for your NCLEX-RN® exam with a clinical question about what actions this nurse should take first to help restore the patient’s cardiac rhythm!
The nurse in the emergency department is caring for a client who recently suffered a myocardial infarction. When the nurse enters the client’s room, they see the following rhythm on the cardiac monitor, and the client is unresponsive without a palpable carotid pulse. Which action should the nurse take first?
A. Lower the head of the bed
B. Establish intravenous access
C. Notify the client’s family members
D. Perform synchronized cardioversion
Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® question is…
A. Lower the head of the bed
Rationale: This client requires cardiopulmonary resuscitation (CPR) to restore a perfusing cardiac rhythm. To perform effective CPR, the nurse should first lower the head of the bed so the client is flat.
Major Takeaway
Cardiac arrest occurs when the heart suddenly stops pumping blood throughout the body. One type of cardiac arrest is asystole or cardiac flatline, where there is a total absence of electrical and mechanical activity in the heart. Priority nursing goals for the client in asystole include performing interventions to restore a perfusing heart rhythm. The nurse should first assess the client’s pulse and respiration. If no pulse is felt within 10 seconds, the nurse should call for assistance and begin cardiopulmonary resuscitation (CPR). CPR consists of high-quality chest compressions at a rate of 100-120 per minute and rescue breathing via bag-mask ventilation with 100% oxygen. Epinephrine 1 mg may be administered every 2-4 minutes intravenously. Because this client requires CPR, the initial step the nurse should take is lowering the head of the bed in order to perform high-quality chest compressions. Intravenous access can be established once CPR is established. Family members can be notified after the event is over. Synchronized cardioversion is not indicated for asystole.
Incorrect Answer Explanations
B. Establish intravenous access
Rationale: Intravenous access should be established quickly so that medications may be administered. However, this is not the priority action.
C. Notify the client’s family members
Rationale: Although notifying the client’s family members is important, it is not the priority action at this time.
D. Perform synchronized cardioversion
Rationale: Synchronized cardioversion is indicated to treat abnormally fast heart rhythms, like atrial fibrillation. Synchronized cardioversion is not indicated to treat asystole; therefore, it is not the priority action at this time.
Want to learn more about this topic?
Watch the Osmosis video: Myocardial infarction (MI): Nursing process (ADPIE)
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