The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly shows asystole. Which action should the nurse take first?

(A) "I’ll breathe deeply and cough every 4 hours."
Deep breathing and coughing exercises should be done more frequently, typically every 1-2 hours while awake, to help prevent respiratory complications such as atelectasis and pneumonia.

(B) "I’ll splint my incision with a pillow to cough."
This statement indicates an understanding of the instructions. Splinting the incision with a pillow helps support the surgical site, reduces pain, and makes coughing more effective and less uncomfortable. This technique is important for clients to use to help clear secretions from the lungs postoperatively.

(C) "I’ll start to use the incentive spirometer when I can get out of bed."
The use of an incentive spirometer should begin as soon as possible, usually while the client is still in bed, to encourage deep breathing and prevent postoperative respiratory complications. It should not be delayed until the client can get out of bed.

(D) "I’ll lie flat in bed to cough and deep breathe."
Lying flat is not the optimal position for deep breathing and coughing exercises, as it can make it more difficult to fully expand the lungs. The client should be positioned with the head of the bed elevated or sitting up to facilitate better lung expansion and more effective coughing.

A. "I will take my warfarin with a glass of water the night before my surgery":

This statement indicates a need for further teaching. Warfarin is an anticoagulant medication, and it should typically be discontinued or adjusted before surgery to reduce the risk of excessive bleeding. Taking it the night before surgery could increase the risk of bleeding during the procedure.

B. "I understand what risks I can expect with this surgery":

This statement suggests that the client has received information about the risks associated with the surgery, which is an essential component of preoperative education. There is no indication for further teaching based on this statement.

C. "I will take time to relax if I get nervous the night before surgery":

This statement demonstrates the client's awareness of the importance of managing stress and anxiety before surgery, which is a positive coping strategy. There is no need for further teaching based on this statement.

D. "I will have a glass of water the morning of my surgery":

This statement is generally acceptable. Clear fluids may be allowed up to a certain time before surgery, depending on the facility's protocol. However, specific instructions regarding fasting before surgery should be clarified with the healthcare provider or surgical team to ensure adherence to preoperative guidelines.