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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:
A. Oxygen is administered during the initial acute phase if the client is hypoxic, to improve myocardial oxygenation, but it does not directly manage pain or anxiety once stabilized.

B. Nitroglycerin is used to relieve chest pain and reduce myocardial workload, primarily in the acute phase of MI. Its use after stabilization is for ongoing ischemia, not specifically for anxiety or persistent pain.

C. Aspirin is an antiplatelet therapy that prevents further clot formation and is continued long-term for MI management, but it does not address acute pain or anxiety.

D. Morphine is indicated after the initial acute phase to manage persistent chest pain and anxiety. It works by reducing myocardial oxygen demand through vasodilation and providing analgesia and sedation, making it appropriate for pain and anxiety management post-acute MI.

A. Increase in blood pressure and heart rate B. Significant weight gain over the past two weeks C. Reduction in peripheral edema and improved breathing D. Development of muscle cramps and weakness

Correct Answer is C

Explanation

Rationale:
A. This would indicate possible fluid retention or worsening heart function, not effective diuretic therapy. Effective diuretics usually help reduce fluid overload, which may lower blood pressure in hypertensive patients.

B. Rapid weight gain is a sign of fluid retention, which suggests diuretic therapy is not effective or the patient’s heart failure is worsening.

C. These findings indicate that excess fluid is being successfully removed from the body. Decreased swelling in the extremities and improved respiratory status reflect effective diuresis and improved cardiac function, which is the goal of therapy.

D. While these can occur due to electrolyte imbalances caused by diuretics, they are adverse effects rather than indicators of effectiveness.

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Which of the following is the initial step in the management of a patient with asystole?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

Correct Answer is D

Explanation

A 65-year-old patient with congestive heart failure has been on diuretic therapy for the past two weeks. During a follow-up appointment, which of the following findings would indicate that the diuretic therapy is effective?

Correct Answer is C

Explanation

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A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

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