A client who has been transported to the emergency room after a motor vehicle accident is experiencing asystole. Management of asystole focuses on:
High-quality CPR with minimal interruptions
Cessation at resuscitation attempts after 2 minutes
Administration of Narcan until an electrical rhythm is obtained
Continuous defibrillation until an electrical rhythm is obtained
The Correct Answer is A
A. High-quality CPR with minimal interruptions is the cornerstone of asystole management. Asystole is a non-shockable rhythm, so maintaining perfusion through effective chest compressions and administering appropriate medications (like epinephrine) is essential.
B. Cessation of resuscitation efforts after only 2 minutes is inappropriate; the decision to stop should be based on the clinical scenario and response to interventions over time.
C. Narcan (naloxone) is used for opioid overdose, not for treating asystole unless there is a suspected opioid-related cause—and it does not directly restore electrical cardiac rhythm.
D. Defibrillation is not indicated in asystole, as it is a non-shockable rhythm. Continuous defibrillation is ineffective and inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sick sinus syndrome – This involves an abnormal SA node function, often with varying rhythm disturbances (e.g., sinus pauses, bradycardia-tachycardia). The strip described is regular and does not reflect these changes.
B. Normal sinus rhythm – The rhythm is regular, the PR interval is within normal limits (0.12–0.20 seconds), the heart rate is 60 beats/min (within the normal range of 60–100), and P waves precede each QRS complex consistently.
C. Sinus bradycardia – Although the rate is 60, which is at the low end of normal, it is not below 60. Bradycardia is defined as <60 bpm.
D. First-degree heart block – First-degree AV block is characterized by a prolonged PR interval >0.20 seconds. The PR interval here is 0.16 seconds, which is normal.
Correct Answer is C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
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