Central Institute of Psychiatry - 9 July 2022
Medical & Surgical Nursing
Hard
A Patient's BP is 80/65 mm of hg and heart rate is not recordable. The patient may go into shock. What would be the first nursing intervention?
Appeared in: Central Institute of Psychiatry - 9 July 2022
Explanation
- The patient's presentation of severe hypotension and an unrecordable heart rate is characteristic of cardiac arrest.
- In this state, the most likely underlying life-threatening arrhythmias are Ventricular Fibrillation (VF) or pulseless Ventricular Tachycardia (pVT).
- According to Advanced Cardiac Life Support (ACLS) protocols, the immediate and highest priority treatment for these 'shockable' rhythms is defibrillation.
- Defibrillation delivers a controlled electrical shock to terminate the chaotic rhythm, providing an opportunity for the heart's natural pacemaker to restore a perfusing rhythm.
Why Other Options Were Wrong
- Option A: Digoxin is a cardiac glycoside used for chronic conditions like heart failure and atrial fibrillation. It is not an emergency resuscitation drug and would be ineffective and inappropriate in a cardiac arrest scenario.
- Option B: Massage, likely referring to carotid sinus massage, is a vagal maneuver. It is used to slow down certain types of fast heart rates (like SVT) in a patient who is conscious and has a pulse. It has no role in a pulseless patient.
- Option C: Subcutaneous (transcutaneous) pacing is an intervention for symptomatic bradycardia (a dangerously slow heart rate) or certain types of heart block. It is not the correct treatment for chaotic, non-perfusing rhythms like VF or pVT.
Related Visual
Clinical Relevance
- Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Management of Cardiac Arrest (Shockable Rhythms) in acute care settings.
- Rapid recognition of cardiac arrest and immediate initiation of the chain of survival (call for help, start high-quality CPR, defibrillate) are critical nursing responsibilities that directly determine patient survival.
- All nurses must be proficient in using a defibrillator, including both manual defibrillators and Automated External Defibrillators (AEDs), as per their facility's protocol.
- This scenario highlights the importance of interpreting a combination of vital signs. The narrow pulse pressure (80/65 mmHg) combined with an unrecordable heart rate is a classic presentation of cardiogenic shock progressing to cardiac arrest.
How to Approach the Question
- First, analyze the patient's vital signs presented in the stem. BP 80/65 mmHg indicates severe hypotension.
- Identify the most critical piece of information: 'heart rate is not recordable'. In a clinical context, this means the patient is pulseless.
- Recognize that a pulseless patient is in cardiac arrest. The question is asking for the first priority action in a cardiac arrest situation.
- Recall the basic principles of ACLS/BLS. The management of cardiac arrest depends on whether the underlying rhythm is 'shockable' or 'non-shockable'.
- An unrecordable, chaotic rhythm is presumed to be shockable (Ventricular Fibrillation or pulseless Ventricular Tachycardia) until proven otherwise.
- Evaluate the options based on the ACLS algorithm. The highest priority for a shockable rhythm is immediate defibrillation. This eliminates the other options which are used for different cardiac conditions.
Concept Tested & Keywords
- Concept Tested: Management of Cardiac Arrest (Shockable Rhythms)
- Stem keywords: BP 80/65 mm of hg, heart rate not recordable, shock, first nursing intervention
- Lead-in keywords: first
- Clinical cues: BP 80/65 mmHg indicates severe hypotension and a narrow pulse pressure (15 mmHg), a classic sign of cardiogenic shock.
- Clinical cues: An 'unrecordable heart rate' is a critical finding that signifies a pulseless state, which is a medical emergency equivalent to cardiac arrest.
Question ID
Qb8tyxPR7A8fcdZLif0ldR
Reference Book
E6 Nursing Vital Signs p. 87-89
E6 Medicine Harrison 22e Part 2 p. 29-31
Practise the full Central Institute of Psychiatry - 9 July 2022
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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