Medical Surgical EKG #10

Question

The nurse nurse’s first priority following initiation of CPR for a client identified as having ventricular fibrillation is to:

Answers

  1. Continue CPR
    • Rationale:

      This answer is not correct because the question indicates that CPR is in progress and the rhythm is identified as ventricular fibrillation. The priority is to administer a shock immediately.

  2. Defibrillate the client
    • Rationale:

      This answer is correct because when a client has a rhythm identified as ventricular fibrillation, the first priority following initiation of CPR is to administer a shock immediately. Ventricular fibrillation is a rapid disorganized ventricular rhythm that causes ineffective quivering of the ventricles. clients may become unresponsive, without a pulse, and may stop breathing. CPR must be initiated immediately. The question indicates that CPR is in progress and rhythm is identified as ventricular fibrillation. The priority is to administer a shock immediately.

  3. Administer calcium IV
    • Rationale:

      This answer is not correct because intravenous calcium is not indicated. When a client has a rhythm identified as ventricular fibrillation, the first priority following initiation of CPR is to administer a shock immediately.

  4. Administer oxygen
    • Rationale:

      This answer is not correct because when a client has a rhythm identified as ventricular fibrillation, the first priority following initiation of CPR is to administer a shock immediately. oxygen would be used if the client was being ventilated with a bag-mask-valve device.

Overview

When a client has a rhythm identified as ventricular fibrillation, the first priority is to administer a shock immediately.

Explanation

Learning Outcomes

Ventricular fibrillation is a rapid disorganized ventricular rhythm that causes ineffective quivering of the ventricles. clients may become unresponsive, without a pulse, and may stop breathing. CPR must be initiated immediately. The question indicates that CPR is in progress and rhythm is identified as ventricular fibrillation. The priority is to administer a shock immediately.

Test Taking Tip

In ventricular fibrillation and pulseless ventricular tachycardia, the client has no pulse, no perfusion and unless the heart is shocked to restore the regular rhythm, thus contraction of the heart, the client will die. Therefore, immediate chest compressions and oxygenation through bag-mask ventilation followed by immediate defibrillation is the client’s only intervention to save their life.

Video Rationale