You are the nurse working on the telemetry unit and you have finally gotten to sit down to
work on some charting. Suddenly the heart monitors at the station start beeping. Patient in
room 18 is showing this rhythm on the monitor. The medical team advances together into the
room and finds them unconscious. What is priority action by the nurse?
A) Prepare to administer adenosine to the patient
B) Begin chest compressions
C) Prepare for defibrillation
D) Check for a pulse
Ans: Answer: D
A pulse would be assessed for first. Then the patient will be defibrillized and chest
compressions will begin immediately.
,The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses
consciousness. The patient is defibrillated, and the rate returns as the following. What should
the nurse do first?
A) Begin compressions
B) Shock the client again immediately
C) Prepare for intubation
D) Administer adenosine
Ans: Answer: A
Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not initiated. The
client may need to be shocked again, but chest compressions must begin first.
The patient with a history of hypertension and diabetes has the following rhythm strip. The
patient's vitals are as follows: BP 145/89, HR 90, SpO2 95%, RR 19. Which of the following does
the nurse expect to do at this time?
a) Prepare the client for cardioversion STAT
b) Begin administering anticoagulants
c) Grab the crash cart for administration of adenosine
d) Teach the client about possibility of pacemaker installation
Ans: Answer: B
Atrial flutter places the client at high risk for development of clot formation in the atria.
Because the client is stable at this time, cardioversion or adenosine would not be performed at
this time. Before cardioversion can occur in a patient, anticoagulant therapy should be begun at
least 48 hours beforehand if possible.
, The nurse is preparing to administer adenosine to the patient with the following rhythm which
is symptomatic. What should the nurse plan on having in the patient room? Select All That
Apply:
a) Physician
b) Crash cart
c) IV pump
d) EKG monitor
e) Lidocaine
Ans: Answer: A, B, and D
Adenosine is administered as a very quick IV push. The physician must be present in the room
and the crash cart must be on hand. An ekg monitor should be in the room to monitor the
effectiveness of the medication.
The nurse has just administered adenosine via IV push and sees the following rhythm on the
monitor. What is the nurse's priority intervention?
a) Apply conductive gel and defibrillate the patient
b) Document the findings and continue to monitor
c) Administer another mg of the medication
d) Begin chest compressions
Ans: Answer: B
This finding would be expected upon administration of adenosine. The rhythm should then
begin again in some other rhythm, hopefully normal sinus rhythm. It would be important to
document the exact time of this change and continue to monitor the change back to NSR. If this
work on some charting. Suddenly the heart monitors at the station start beeping. Patient in
room 18 is showing this rhythm on the monitor. The medical team advances together into the
room and finds them unconscious. What is priority action by the nurse?
A) Prepare to administer adenosine to the patient
B) Begin chest compressions
C) Prepare for defibrillation
D) Check for a pulse
Ans: Answer: D
A pulse would be assessed for first. Then the patient will be defibrillized and chest
compressions will begin immediately.
,The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses
consciousness. The patient is defibrillated, and the rate returns as the following. What should
the nurse do first?
A) Begin compressions
B) Shock the client again immediately
C) Prepare for intubation
D) Administer adenosine
Ans: Answer: A
Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not initiated. The
client may need to be shocked again, but chest compressions must begin first.
The patient with a history of hypertension and diabetes has the following rhythm strip. The
patient's vitals are as follows: BP 145/89, HR 90, SpO2 95%, RR 19. Which of the following does
the nurse expect to do at this time?
a) Prepare the client for cardioversion STAT
b) Begin administering anticoagulants
c) Grab the crash cart for administration of adenosine
d) Teach the client about possibility of pacemaker installation
Ans: Answer: B
Atrial flutter places the client at high risk for development of clot formation in the atria.
Because the client is stable at this time, cardioversion or adenosine would not be performed at
this time. Before cardioversion can occur in a patient, anticoagulant therapy should be begun at
least 48 hours beforehand if possible.
, The nurse is preparing to administer adenosine to the patient with the following rhythm which
is symptomatic. What should the nurse plan on having in the patient room? Select All That
Apply:
a) Physician
b) Crash cart
c) IV pump
d) EKG monitor
e) Lidocaine
Ans: Answer: A, B, and D
Adenosine is administered as a very quick IV push. The physician must be present in the room
and the crash cart must be on hand. An ekg monitor should be in the room to monitor the
effectiveness of the medication.
The nurse has just administered adenosine via IV push and sees the following rhythm on the
monitor. What is the nurse's priority intervention?
a) Apply conductive gel and defibrillate the patient
b) Document the findings and continue to monitor
c) Administer another mg of the medication
d) Begin chest compressions
Ans: Answer: B
This finding would be expected upon administration of adenosine. The rhythm should then
begin again in some other rhythm, hopefully normal sinus rhythm. It would be important to
document the exact time of this change and continue to monitor the change back to NSR. If this
