A nurse is participating in a Code Blue. Which actions are important to maintain therapeutic communication during the code? Select all that apply.

Choice A rationale

To ensure a continuous flow of flush solution through the arterial catheter and prevent blood from backing up into the tubing, the pressure bag must be maintained at 300 mm Hg. This high pressure overcomes the patient's arterial pressure, which normally ranges from 100 to 140 mm Hg systolic. This constant flow of approximately 3 mL per hour maintains patency of the line and prevents clot formation at the catheter tip, ensuring accurate readings.

Choice B rationale

An arterial line is strictly used for hemodynamic monitoring and arterial blood gas sampling, not for the administration of medications or intravenous fluids. Injecting antibiotics or other drugs into an arterial line can cause severe vasospasm, arterial occlusion, and potential tissue necrosis or gangrene in the distal limb. All intravenous medications must be administered through a venous access device, such as a peripheral IV or a central venous catheter, to ensure systemic distribution.

Choice C rationale

Bearing down, or the Valsalva maneuver, increases intra-thoracic and intra-abdominal pressure, which temporarily alters venous return and blood pressure readings. This would result in inaccurate hemodynamic data, as the arterial line is meant to measure the patient's physiological baseline or response to therapy. The patient should remain quiet and still in a supine or semi-Fowler's position with the transducer leveled at the phlebostatic axis to obtain the most reliable and consistent blood pressure measurements.

Choice D rationale

The Trendelenburg position, where the head is lower than the feet, is used to increase venous return or during certain central line insertions, but it is not appropriate for obtaining arterial line readings. Hemodynamic measurements should be taken with the patient in a neutral position. The transducer must be leveled at the phlebostatic axis, which is the fourth intercostal space at the mid-axillary line, to ensure the hydrostatic pressure does not skew the recorded blood pressure.

Choice C rationale

Asystole, or ventricular standstill, must be confirmed in at least two different leads to rule out fine ventricular fibrillation or technical errors like a loose lead. Treating "false" asystole can delay life-saving defibrillation if the patient is actually in a shockable rhythm. Assessment is the first step in the nursing process. Verifying the rhythm and checking the patient's pulse ensures that the clinical intervention matches the true physiological state of the patient.

Choice A rationale

Epinephrine is the primary medication used during the resuscitation of a patient in asystole according to ACLS guidelines. It works by causing peripheral vasoconstriction and increasing coronary perfusion pressure. However, the nurse should never administer medication based on a monitor rhythm alone without first assessing the patient and confirming the rhythm in multiple leads. Once confirmed and CPR is initiated, epinephrine 1 mg is given every 3 to 5 minutes during the arrest.

Choice B rationale

Intubation is an important part of advanced airway management during cardiac arrest to ensure adequate oxygenation and protection against aspiration. While it is a component of the ACLS algorithm, it is not the initial action. The nurse must first verify the rhythm and begin high-quality chest compressions. Airway management often occurs simultaneously with or after the initiation of CPR and the confirmation of the cardiac arrest rhythm to maximize perfusion.

Choice D rationale

Atropine was previously included in the asystole algorithm to treat potential vagal discharge, but it is no longer recommended by the American Heart Association for asystole or pulseless electrical activity. Current protocols focus on high-quality CPR and early epinephrine administration. Administering atropine would be an outdated practice and does not address the primary need for assessment and perfusion in a patient who has no detectable electrical activity or mechanical pulse.