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?
Document the rhythm as normal.
Start cardiopulmonary resuscitation (CPRL
Prepare the patient for cardioversion.
Prepare to administer atropine
The Correct Answer is B
(A) Document the rhythm as normal: Asystole is a serious condition characterized by a flatline ECG, indicating no electrical activity in the heart. It is not a normal rhythm and requires immediate intervention.
(B) Start cardiopulmonary resuscitation (CPR): This is the most appropriate initial action. Asystole is a life-threatening condition that requires immediate intervention. The first step should be to start CPR and call for help.
(c) Prepare the patient for cardioversion: Cardioversion is typically used to treat conditions where the heart is beating irregularly (arrhythmias), but not when there is no electrical activity at all (asystole).
(D) Prepare to administer atropine: Atropine is sometimes used in the treatment of bradycardia (slow heart rate), not asystole. In the case of asystole, epinephrine is more commonly administered during resuscitation efforts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(A) Respiratory acidosis: Respiratory acidosis is characterized by a low pH (<7.35) and a high PaCO2 (>45 mm Hg). In this case, the client’s pH is high and PaCO2 is normal, which rules out respiratory acidosis.
(B) Respiratory alkalosis: Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mm Hg). Although the client’s pH is high, the PaCO2 is normal, which rules out respiratory alkalosis.
(C) Metabolic acidosis: Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L). The client’s pH and bicarbonate levels are both high, which rules out metabolic acidosis.
(D) Metabolic alkalosis: Metabolic alkalosis is characterized by a high pH (>7.45) and a high bicarbonate level (>26 mEq/L). The client’s pH is 7.6 and bicarbonate level is 32 mEq/L, both of which are higher than normal. This indicates metabolic alkalosis. Therefore, the nurse should identify that the client is experiencing metabolic alkalosis.
Correct Answer is A
Explanation
A. The ST segment is elevated above the isoelectric line: This is correct. ST-segment elevation is a key ECG finding in acute myocardial infarction. It indicates that a portion of the heart muscle is not receiving enough blood (ischemia), which can lead to tissue damage or death (infarction).
B. The PR intervals are 0.15 second: While the PR interval is an important part of the ECG, a PR interval of 0.15 second is within the normal range and does not indicate an acute myocardial infarction.
C. The QT interval is equal to the R to R interval: The QT interval represents the time from the start of the Q wave to the end of the T wave, encompassing ventricular depolarization and repolarization. While prolonged or shortened QT intervals can be associated with certain cardiac conditions, they are not specific indicators of an acute myocardial infarction.
D. The QRS intervals are 0.08 second: The QRS interval represents ventricular depolarization1. A QRS interval of 0.08 second is within the normal range and does not indicate an acute myocardial infarction.
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