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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

D. A pulmonary artery catheter is used to monitor hemodynamic status. It provides valuable information about cardiac function, preload, afterload, and cardiac output. By measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, and central venous pressure, a pulmonary artery catheter helps assess the effectiveness of cardiac function and guide management in critically ill patients, especially those with conditions such as heart failure, shock, or pulmonary hypertension.

A. A pulmonary artery catheter, also known as a Swan-Ganz catheter, is not used to monitor intracranial pressure. Instead, it is primarily used to assess hemodynamic status and cardiac function by measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, central venous pressure, and cardiac output.

B. A pulmonary artery catheter is not used to directly monitor renal function. While changes in hemodynamic status can impact renal perfusion and function, the primary purpose of a pulmonary artery catheter is to assess cardiac function and hemodynamics, rather than renal function.

C. A pulmonary artery catheter is not used to monitor spinal cord perfusion. Although alterations in hemodynamic status can affect spinal cord perfusion indirectly, the main purpose of a pulmonary artery catheter is to evaluate cardiac function and hemodynamics.

A. Hypokalemia B. Heart rate 160/min C. Mottled skin D. Blood pressure 115/68 mmHg

Correct Answer is B

Explanation

B. Tachycardia is a compensatory mechanism aimed at increasing cardiac output and maintaining tissue perfusion. In response to decreased perfusion, the body increases heart rate to improve circulation and oxygen delivery to tissues.
A. Hypokalemia, or low potassium levels, is not typically associated with the compensatory stage of shock. Instead, electrolyte imbalances may develop later in the progression of shock due to tissue hypoperfusion and metabolic disturbances.
C. Mottled skin, characterized by patchy discoloration due to uneven blood flow, is more commonly seen in the progressive or irreversible stages of shock. It indicates significant tissue hypoperfusion and impaired microcirculation, rather than the compensatory stage
D. This blood pressure reading is within the normal range and may be maintained during the compensatory stage of shock. Initially, blood pressure may be maintained or only slightly decreased due to compensatory mechanisms such as vasoconstriction. However, blood pressure can decrease further as shock progresses beyond the compensatory stage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Correct Answer is D

Explanation

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGS? pH 7.22 PaCO2 68 mm Hg Base excess-2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Mr Jones came to the ER complaining of chest palpitations. He states his heart feels like it is "racing". The nurse found the following rhythm on the monitor. What is the next step would the nurse expect to take first?

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)