While bathing a patient, the nurse notes that the patient's cardiac monitor appears to reveal ventricular fibrillation (V-Fib). What is the nurse's priority action?
Explanation
•It is most appropriate for the nurse to immediately assess a patient with a suspected ventricular fibrillation rhythm. The nurse is bathing this patient and it is possible that the rhythm observed is an artifact and not a true rhythm. By assessing the patient first, the nurse is confirming what the action should be.
Incorrect options:
•Synchronized cardioversion is not appropriate for this patient. Synchronized cardioversion delivers a low voltage shock that is timed (synchronized) with the R wave of the patient's EKG. The indications for synchronized cardioversion are for unstable atrial rhythms, not ventricular rhythms such as ventricular fibrillation.
•While calling a code and obtaining a crash cart is appropriate for a patient with true ventricular fibrillation, this patient does not have a confirmed ventricular fibrillation cardiac rhythm and further assessment is more appropriate. Because the nurse is bathing the patient, it is possible that the rhythm is an artifact and not a true ventricular fibrillation.
•Immediately paging the physician is not the most appropriate action by the nurse. The patient requires immediate attention by the nurse and calling the physician does not meet this requirement.