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) "A heating pad will be used on the operative site to help reduce pain.":
Using a heating pad on the operative site is generally not recommended post-surgery, as it can increase bleeding and swelling. Cold therapy is usually preferred to help reduce pain and inflammation.
(B) "You will use a continuous passive motion (CPM) machine several times a day.":
Continuous passive motion machines are typically used after knee replacement surgeries, not hip replacement surgeries. Therefore, this statement would not be accurate for a total hip replacement.
(C) "Expect to remain in bed for at least the first 24 hours.":
Early mobilization is crucial after hip replacement surgery to prevent complications such as deep vein thrombosis and to promote recovery. Patients are usually encouraged to get out of bed and start moving with assistance as soon as possible, often within the first 24 hours.
(D) "You will use a special soap to shower with the evening before your surgery.":
Using a special antiseptic soap before surgery is a common preoperative instruction to help reduce the risk of infection. This statement is correct and should be included in the preoperative teaching.
Correct Answer is B
Explanation
B) "I will keep my house at a cool temperature": This statement indicates a need for further teaching because maintaining a warm environment is recommended for individuals with Raynaud's phenomenon to prevent vasoconstriction and reduce the risk of attacks. Cold temperatures can trigger symptoms in individuals with this condition. Therefore, advising the client to keep their house warm is appropriate and aligns with preventive measures for Raynaud's phenomenon.
A) "I will try to anticipate and avoid stressful situations": Stress management is an essential aspect of managing Raynaud's phenomenon, as stress can trigger vasospasms. Anticipating and avoiding stressful situations can help reduce the frequency and severity of symptoms.
C) "I will complete the smoking cessation program I started": Smoking cessation is crucial for individuals with Raynaud's phenomenon because smoking narrows blood vessels and exacerbates symptoms. Completing a smoking cessation program is a positive step toward reducing the risk of vasospasms.
D) "I will wear gloves when removing food from the freezer": Wearing gloves when handling cold objects, such as food from the freezer, is recommended for individuals with Raynaud's phenomenon to prevent triggering attacks due to exposure to cold temperatures. This statement demonstrates an understanding of preventive measures for managing the condition.
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