The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly shows asystole. Which action should the nurse take first?
Document the rhythm as normal.
Start cardiopulmonary resuscitation (CPRL
Prepare the patient for cardioversion.
Prepare to administer atropine
The Correct Answer is B
(A) Document the rhythm as normal: Asystole is a serious condition characterized by a flatline ECG, indicating no electrical activity in the heart. It is not a normal rhythm and requires immediate intervention.
(B) Start cardiopulmonary resuscitation (CPR): This is the most appropriate initial action. Asystole is a life-threatening condition that requires immediate intervention. The first step should be to start CPR and call for help.
(c) Prepare the patient for cardioversion: Cardioversion is typically used to treat conditions where the heart is beating irregularly (arrhythmias), but not when there is no electrical activity at all (asystole).
(D) Prepare to administer atropine: Atropine is sometimes used in the treatment of bradycardia (slow heart rate), not asystole. In the case of asystole, epinephrine is more commonly administered during resuscitation efforts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Mannitol:
Mannitol is an osmotic diuretic that works by increasing the osmotic pressure in the glomerular filtrate, leading to increased urine output. It is not associated with causing hyperkalemia.
B) Spironolactone:
This is the correct choice. Spironolactone is a potassium-sparing diuretic that can put clients at risk for hyperkalemia. It works by blocking the action of aldosterone in the distal tubules of the kidneys, leading to decreased sodium reabsorption and increased potassium retention.
C) Hydrochlorothiazide:
Hydrochlorothiazide is a thiazide diuretic that promotes the excretion of sodium and water and can lead to potassium depletion (hypokalemia) rather than hyperkalemia.
D) Furosemide:
Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the ascending loop of Henle. It can lead to potassium depletion (hypokalemia) rather than hyperkalemia.
Correct Answer is B
Explanation
A) Describe the surgery and what the client will experience postoperatively:
While it is essential to provide information about the surgery and the postoperative experience, the primary focus of preoperative teaching is to ensure that the client understands the information provided. This option does not specifically address the client's level of understanding, which is crucial for effective teaching.
B) Reinforce information at the client's level of understanding:
This is the correct choice. When contributing to the preoperative teaching plan, the nurse should ensure that information is provided in a way that the client can comprehend. Reinforcing information at the client's level of understanding enhances communication and ensures that the client is well-informed about the procedure and what to expect.
C) Reassure the client that the surgery rarely has any negative outcomes:
While it is important to provide reassurance and support to the client, it is not appropriate to make promises or provide guarantees about the outcome of the surgery. Surgery, by its nature, carries risks, and it is essential to provide the client with accurate information while maintaining a supportive and empathetic approach.
D) Notify the client's family of the plan of care:
While it is important to involve the client's family in the plan of care, the primary focus of preoperative teaching is on the client. Involving the family in the plan of care is important, but it is not the most immediate action in the context of preoperative teaching.
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