The nurse is interpreting cardiac monitoring on the rhythm below. What non-invasive priority action the nurse would take based on the rhythm?
Explanation & Rationale
A. Take the client's blood pressure.: Measuring blood pressure is important for assessing perfusion, but it takes time and does not immediately assess the presence of a pulse or the client’s hemodynamic stability. In ventricular tachycardia (V-tach), rapid action is needed to determine if the client is perfusing before other interventions. B. Check the client's peripheral pulses.: The first non-invasive priority is to assess whether the client has a palpable pulse, which determines if the V-tach is pulse-present (stable) or pulseless (unstable). This guides immediate interventions, such as preparing for synchronized cardioversion in a pulsed client or initiating CPR in a pulseless client. Assessing pulses quickly identifies life-threatening instability. C. Administer adenosine intravenous push (IVP) to the client.: Adenosine is indicated for supraventricular tachycardia (SVT), not ventricular tachycardia. Administering adenosine in V-tach can worsen the arrhythmia or precipitate cardiac arrest. D. Instruct the client to perform the Valsalva maneuver.: The Valsalva maneuver is used to terminate certain supraventricular tachycardias by increasing vagal tone. It is ineffective and unsafe for ventricular tachycardia, which originates in the ventricles and may rapidly deteriorate into ventricular fibrillation.