The nurse is caring for a client in the cardiac unit and notices the client’s rhythm changes from normal sinus rhythm to coarse ventricular fibrillation. Which is the priority nursing action?

  1. call a code blue
  2. check the client and check the leads
  3. initiate CPR while waiting on help to arrive
  4. prepare to start the client on a diltiazem (Cardizem) drip
  5. clear the room of unnecessary items to allow room for the crash cart and team
Number 2 is correct.
Rationale: The priority with any dysrhythmia is to check the client and the leads first to ensure that the client is truly having a rhythm change. Improperly placed or loose leads can mimic dysrhythmias; coughing or movement can create artifacts. Ventricular fibrillation is a life-threatening emergency; once the client is checked, the nurse should immediately call a code and initiate CPR when the backboard arrives. While waiting on the crash cart, the client should be positioned flat with the rails down for access. If the client is not intubated, pull the bed away from the wall for the anesthetist. The room should be cleared of furniture or other items that will crowd the room. Diltiazem is given in cases of supraventricular tachycardia and is not part of the ACLS protocol for treatment of ventricular fibrillation. Drugs are given only after shocking the client to stabilize the rhythm and improve cardiac output.