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 B
Explanation
A. Root cause analysis:
Root cause analysis is a method used to identify the underlying causes of adverse events or errors. While it is important for quality improvement and risk management, it does not specifically involve using research and scientific data to guide clinical decision-making in client care.
B. Evidence-based practice:
Evidence-based practice (EBP) involves integrating the best available evidence from research studies with clinical expertise and patient preferences to guide decision-making in client care. By utilizing research and scientific data, nurses can identify effective interventions and strategies to improve client outcomes.
C. Benchmarking:
Benchmarking involves comparing performance metrics or outcomes against standards or best practices. While benchmarking can inform quality improvement efforts, it does not directly involve using research and scientific data to guide clinical decision-making.
D. Standardization:
Standardization involves implementing consistent processes or protocols to improve quality and safety. While standardization is important for ensuring consistency in care delivery, it does not necessarily rely on research and scientific data to inform clinical decision-making as evidence-based practice does.
Correct Answer is C
Explanation
A. Hypoglycemia: Hypoglycemia, or low blood sugar, is not typically associated with hypokalemia. Hypokalemia is a condition characterized by low levels of potassium in the blood. While both conditions can occur due to certain diseases or medication use, they are not directly related.
B. Hyperreflexia: Hyperreflexia, a condition characterized by overactive reflexes, is not a common symptom of hypokalemia. Hypokalemia primarily affects muscle function, leading to symptoms such as muscle weakness, cramps, and potentially cardiac dysrhythmias. It does not typically cause an overactive reflex response.
C. Cardiac dysrhythmias: This is correct. Hypokalemia can lead to cardiac dysrhythmias. Potassium plays a crucial role in maintaining normal electrical activity in the heart. When potassium levels are low, it can disrupt this electrical activity, leading to irregular heart rhythms.
D. Increased appetite: Increased appetite is not a typical symptom of hypokalemia. In fact, loss of appetite is more commonly associated with this condition. Severe hypokalemia can affect the functioning of the muscles in the digestive system, leading to symptoms such as bloating, constipation, and abdominal pain.
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