The rapid response team (RRT) is caring for a client with asystole. Which nursing statement made to the client's family about the actions of the RRT is appropriate?
The rapid response team will begin with defibrillation and then progress to cardiopulmonary resuscitation if needed
It would be best if you waited outside, as you won't want to see cardiopulmonary resuscitation performed on your loved one
As long as the team is doing cardiopulmonary resuscitation, your loved on has a normal blood flow throughout their body
The rapid response team cannot defibrillate your loved on because they are in systole; they are continuing cardiopulmonary resuscitation.
The Correct Answer is D
D. Asystole represents the absence of electrical activity in the heart and is not amenable to defibrillation. Therefore, the RRT would continue cardiopulmonary resuscitation (CPR) with chest compressions and may administer medications or other interventions as indicated. This statement provides accurate information to the family about the patient's condition and the actions being taken by the RRT.
A. Defibrillation is not indicated for asystole. Asystole represents a flatline on the cardiac monitor, indicating the absence of electrical activity in the heart. Defibrillation is only effective for certain types of cardiac rhythms, such as ventricular fibrillation or pulseless ventricular tachycardia. Therefore, the RRT would not use defibrillation for a patient in asystole.
B. It does not provide the family with information about the patient's condition or the actions being taken by the RRT. Moreover, excluding the family from the patient's care may cause additional distress and prevent them from being present to support their loved one during a critical situation.
C. Cardiopulmonary resuscitation (CPR) is performed to maintain blood flow and oxygenation to vital organs during cardiac arrest. However, it does not restore normal blood flow or circulation. The goal of CPR is to provide temporary support until advanced interventions can be initiated or until return of spontaneous circulation (ROSC) is achieved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pacemaker spikes before each QRS complex: This is the correct answer. In a client with a ventricular pacemaker, the pacemaker spikes should precede each QRS complex on the ECG strip. This indicates that the pacemaker is appropriately stimulating the ventricles to depolarize and initiate a heartbeat. The
presence of pacemaker spikes before each QRS complex signifies that the pacemaker is functioning properly and effectively pacing the ventricles.
B. Pacemaker spikes occurring after each QRS complex would suggest a malfunction or inappropriate timing of the pacemaker. In this scenario, the pacemaker would not be pacing the ventricles as intended. This would be an abnormal finding and would require further assessment and intervention.
C. Pacemaker spikes preceding each P wave would suggest pacing of the atria rather than the ventricles. This would indicate a different type of pacemaker (atrial pacemaker) or inappropriate pacing settings for a ventricular pacemaker. In either case, it would be considered abnormal for a ventricular pacemaker and would require evaluation and possibly reprogramming of the pacemaker.
D. Pacemaker spikes occurring with each T wave would be an abnormal finding and would suggest interference or oversensing by the pacemaker. This could lead to inappropriate pacing or dysrhythmias. It would require further investigation and correction to ensure proper pacemaker function.
Correct Answer is A
Explanation
A Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
B Low dose dopamine is not a contraindication to epinephrine administration.
C A sinus tachycardia is not a contraindication to epinephrine administration
D Lack of urine output is not a contraindication to epinephrine administration
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