Health Promotion and Maintenance
76. While preparing for an admission, a nurse hears the alarm sound on the cardiac monitor of a child in the next bed. The nurse views the screen and sees what appears to be ventricular fibrillation. What is the best initial action by the nurse?
Test-Taking Tip
In this question the priority is assessment before action.
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because the nurse is taking action before first assessing the child. Answer 2 is correct because the nurse should first assess the child's physical condition before assuming that the monitor is accurate. The monitor could be displaying an artifact as a result of the child's activity. Answer 3 is incorrect because the nurse is taking action before first assessing the child. Answer 4 is incorrect because the nurse is taking action before first assessing the child.
