Difficulty: Medium
Average Score: 67%
Simulated
Passage / Scenario
The following scenario applies to the next 1 itemsThe nurse cares for a client admitted for a myocardial infarction
Item 1 of 1
Nurses' Note
0800 - Client was found in bed pale and diaphoretic, stating, I do not feel well. Approximately two minutes later, the cardiac monitor showed ventricular tachycardia. Upon assessment, the client became unresponsive and did not have a pulse.
For each potential intervention, click to specify if it is essential or contraindicated: A. Call a code blue, B. Cardiovert the client, C. Defibrillate the client, D. Anticipate a prescription for intravenous digoxin, E. Perform chest compressions
Correct answer
A,C,E
Rationale
A: Essential - Calling a code blue activates the emergency response team for immediate intervention. B: Contraindicated - Cardioversion is used for synchronized shocks in stable rhythms like atrial fibrillation, not for pulseless ventricular tachycardia. C: Essential - Defibrillation is the treatment for pulseless ventricular tachycardia to restore a viable rhythm. D: Contraindicated - Digoxin is not used in acute cardiac arrest; it is for heart failure or rate control in arrhythmias. E: Essential - Chest compressions are required in pulseless clients as part of CPR.