Medical Surgical Critical Care Cardiac Critical Care #5

Question

A client brought in by the ambulance is admitted straight to the intensive care unit with this rhythm:

Which intervention is priority for the nurse?

Answers

  1. Transesophagus echocardiogram (TEE).
    • Rationale:

      This answer is not correct because a transesophagus echocardiogram (TEE) is used to assess function as well as structure of our heart. A TEE is used when the health care provider wants a closer look at the heart to check for clots. This is not treatment for Vfib.

  2. CPR and then Cardioversion.
    • Rationale:

      This answer is not correct because although CPR is indicated first, cardioversion is not and defibrillation is key.

  3. Lovenox 80 mg SQ.
    • Rationale:

      This answer is not correct because although Lovenox 80 mg SQ is given prophylactically to prevent blood clots while hospitalized, it is not the priority treatment for Vfib.

  4. CPR and then Defibrillation.
    • Rationale:

      This answer is correct because cardiopulmonary resuscitation (CPR) should be started ASAP, then defibrillation. The heart is shocked to depolarize the critical mass from the excitable myocardium. Because the electrical signals notify the heart muscles to pump causing the ventricles to fibrillate or quiver instead. This in turn keeps the blood from pumping to the rest of the body. Treatment must be immediate for better outcomes.

Overview

This client was admitted to the intensive care unit with ventricular fibrillation. With ventricular fibrillation or Vfib, the ventricles quiver rather than pumping normally.

Explanation

Learning Outcomes

This client was admitted to the intensive care unit with ventricular fibrillation. With ventricular fibrillation or Vfib, the ventricles quiver rather than pumping normally. Cardiopulmonary resuscitation should be started ASAP, then defibrillation. The heart is shocked to depolarize the critical mass from the excitable myocardium. Because the electrical signals notify the heart muscles to pump causing the ventricles to fibrillate or quiver instead. This in turn keeps the blood from pumping to the rest of the body. Treatment must be immediate for better outcomes.

Test Taking Tip

Know the different rhythms of ventricular tachycardia and ventricular fibrillation and the priority treatments of each.

Video Rationale