A nurse is caring for a 75-year-old patient with a history of myocardial infarction being monitored in the cardiac unit. The patient suddenly develops ventricular tachycardia with a heart rate of 160 bpm on the cardiac monitor, remains conscious but complains of lightheadedness and nausea. What is the nurse's priority action?

Synchronized cardioversion is priority for ventricular tachycardia with hemodynamic compromise (chest pain, dizziness) to quickly restore normal rhythm. Other actions (oxygen, ECG, medication) are important but secondary in this unstable situation.

Core Nursing Explanation Key Concept Analysis: This question tests the critical nursing skill of differentiating between stable and unstable Ventricular tachycardia (VT) and identifying the immediate priority intervention. The core principle is the ABCs (Airway, Breathing, Circulation) and the concept of "perfusion vs. rhythm." When a life-threatening arrhythmia compromises cardiac output and perfusion to vital organs, the priority is to restore effective circulation immediately, not just to diagnose or treat the rhythm itself with medications.

Answer Rationale: The patient is experiencing unstable ventricular tachycardia. Key indicators of instability are the symptoms of lightheadedness and nausea, which signify cerebral hypoperfusion. The patient is conscious now, but this is a rapidly deteriorating situation. Key Point! For unstable VT (or any unstable tachyarrhythmia with signs of poor perfusion like hypotension, chest pain, altered mental status, or heart failure), the immediate treatment per Advanced Cardiac Life Support (ACLS) guidelines is synchronized cardioversion. This delivers a timed electrical shock to depolarize the entire myocardium simultaneously, allowing the sinoatrial (SA) node to resume control and restore a perfusing rhythm. Preparing for this procedure is the nurse's top priority action to prevent cardiac arrest.

Distractor Analysis:
① Administering oxygen is a supportive measure for any patient in distress but does not address the root cause—the ineffective cardiac rhythm. It is not the priority when circulation is acutely compromised.
③ Obtaining a 12-lead ECG is a diagnostic step that provides more detail about the arrhythmia's origin. However, in an unstable patient, treatment should not be delayed for diagnostics. A rhythm strip from the monitor is sufficient to identify VT and proceed with emergency treatment.
④ Administering an antiarrhythmic medication (e.g., amiodarone, lidocaine) is part of the ACLS algorithm for stable VT. If the patient had no symptoms of poor perfusion, medication might be the first-line treatment. In this unstable scenario, cardioversion comes first; medications are often given during or after the procedure to maintain stability.

Related Concepts: This scenario highlights the fundamental nursing responsibility of rapid assessment and intervention. The nurse must continuously assess for changes in stability (e.g., loss of consciousness, drop in blood pressure) and be ready to escalate care, including initiating CPR and defibrillation if the patient deteriorates to pulseless VT or Ventricular Fibrillation (VF). Concept Summary

Concept

Definition & Key Point

Unstable VT

Ventricular tachycardia WITH signs of poor perfusion (e.g., hypotension 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in a step-down cardiac unit. Your patient, Mr. Johnson, has a history of an anterior MI. While you are charting, his monitor alarm sounds, showing a run of VT at 160 bpm. You rush in, find him pale, diaphoretic, and complaining, "I feel really dizzy and sick to my stomach." His radial pulse is rapid and weak. Nursing Intervention Strategy: Immediate Action (Seconds 0-30): Key Point! Assess responsiveness and check a pulse. Confirm the monitor rhythm matches the patient's clinical status. Since he has a pulse but is symptomatic, you immediately shout for help and call a Code Blue or Rapid Response while grabbing the crash cart. Your priority is to prepare for synchronized cardioversion. During Preparation (Seconds 30-90): As your team arrives, you quickly: Apply oxygen via non-rebreather mask at 15 L/min (not a low-flow nasal cannula in this emergency). Attach defibrillator pads to the patient's chest (antero-apical position). Ensure the defibrillator is in SYNC mode (look for sync markers on the QRS complexes on the screen). Obtain IV access if not already present. Briefly explain the procedure to the patient if possible: "Mr. Johnson, your heart is racing. We need to give it a gentle shock to get it back to normal rhythm. We'll give you medicine to make you sleepy first." Procedure (Seconds 90-180): The physician or ACLS-trained provider will order sedation (e.g., Midazolam, Fentanyl). Once the patient is sedated, the team clears the bed, and the synchronized shock is delivered. You document the time, energy level, rhythm before and after, and the patient's response. Post-Cardioversion Care: Continuously monitor vital signs, oxygen saturation, and cardiac rhythm. Assess the patient's level of consciousness, skin for burns under the pads, and peripheral pulses. Prepare to administer antiarrhythmic medications as ordered to maintain stability. Patient Safety and Precautions: Sync Mode is MANDATORY: Never cardiovert a patient with a pulse in unsynchronized mode. Failing to sync can deliver the shock on the T-wave and induce Ventricular Fibrillation (R-on-T phenomenon). Sedation: Cardioversion is painful. Adequate sedation and analgesia are required for any conscious patient. Clearance: Loudly announce "CLEAR!" and visually ensure no one is touching the patient or the bed before delivering the shock. Nursing Procedure & Medication Flow Procedure: Assisting with Synchronized Cardioversion 1. Assess patient: Pulse? Conscious? Symptoms of instability? 2. Call for help / Activate emergency response. 3. Apply supplemental oxygen. 4. Turn on defibrillator, select "SYNC" mode (verify sync markers appear on QRS). 5. Apply conductive pads to clean, dry skin (right sternal border, left mid-axillary line). 6. Connect pads to defibrillator. 7. Select appropriate energy level (e.g., 100 J monophasic for VT, often start lower for atrial arrhythmias). 8. Administer sedation/analgesia as ordered and ensure patient is adequately sedated. 9. Charge the defibrillator. 10. Announce "CLEAR!" and verify visually that all personnel are clear. 11. Press the shock button(s). 12. Immediately reassess rhythm and pulse. Medication Cautions: Amiodarone: IV push can cause significant hypotension. Infuse slowly per protocol and monitor BP closely. It is a first-line drug for stable VT and for shock-refractory VF/pulseless VT. Sedatives (Midazolam): Monitor respiratory status closely. Have bag-valve-mask (BVM) and suction ready. A Word from Your Senior Nurse "In the heat of a cardiac emergency, your brain might scream to do ten things at once. Remember your training: Assess, Call, Care. First, assess the patient—not just the monitor. A conscious patient complaining of dizziness with VT is a five-alarm fire. Your role is to initiate the life-saving protocol immediately. On the NCLEX and in real life, they are testing your clinical judgment. Knowing that electricity trumps medication in an unstable patient is a non-negotiable rule. Stay calm, trust your knowledge, and be the confident advocate your patient needs in that critical moment." 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.