Which of the following is the initial step in the management of a patient with asystole?
Check for a pulse every 30 seconds
Administer 1 mg of epinephrine
Administer a defibrillation shock
Begin chest compressions immediately
The Correct Answer is D
Rationale:
A. In a patient with asystole, a pulse check is not performed repeatedly in 30-second intervals; the rhythm is already pulseless, so delaying intervention to check the pulse wastes critical time.
B. Epinephrine is an important medication in asystole management, but it is administered after initiating CPR, not as the first step. Immediate medication without circulation is ineffective.
C. Defibrillation is ineffective in asystole because there is no organized electrical activity to reset. Defibrillation is reserved for shockable rhythms such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).
D. This is the correct initial step because asystole represents a complete absence of cardiac electrical activity, and immediate high-quality CPR is essential to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions increases the chance of survival while advanced life support measures (airway, epinephrine) are prepared.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Rationale:
A. A thready, weak pulse is typically associated with fluid volume deficit, not excess. Clients with FVE often have bounding pulses due to increased intravascular volume.
B. Dizziness is more commonly a sign of hypovolemia or hypotension, rather than fluid overload.
C. Edema occurs when excess fluid accumulates in the interstitial spaces, commonly in the lower extremities in clients with heart failure, making it a classic manifestation of FVE.
D. FVE usually causes distended (full) neck veins due to increased central venous pressure. Flat neck veins are associated with hypovolemia.
E. Rapid or unexplained weight gain in a client with HF is an early sign of fluid retention and is commonly used to monitor FVE.
Correct Answer is B
Explanation
Rationale:
A. While infection monitoring is important, the risk immediately post-procedure is low; infection typically develops later, not immediately.
B. Immediately following a heart catheterization, there is a risk of arrhythmias, bleeding, or hemodynamic instability, making continuous monitoring of cardiac rhythm and vital signs critical to detect complications early.
C. Routine glucose monitoring is not specifically indicated unless the patient has diabetes; it is not a priority related to the catheterization procedure.
D. While ongoing hydration and diet are part of overall care, they are not immediate priorities in the immediate post-catheterization period.
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