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?

A. Vomiting:

Vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach, resulting in increased bicarbonate levels in the blood. It does not directly contribute to metabolic acidosis.

B. Hyperventilation:

Hyperventilation can lead to respiratory alkalosis due to excessive elimination of carbon dioxide (CO2) through increased respiratory rate and depth. It is not associated with metabolic acidosis.

C. Diarrhea:

Diarrhea can lead to metabolic acidosis due to the loss of bicarbonate-rich fluid from the gastrointestinal tract, resulting in decreased bicarbonate levels in the blood. While diarrhea can contribute to metabolic acidosis, it is not the case in this scenario.

D. Salicylate intoxication:

Salicylate intoxication, such as aspirin overdose, can lead to metabolic acidosis due to the accumulation of salicylic acid, which is a weak acid that dissociates in the body, contributing to an increased anion gap metabolic acidosis. This is a direct cause of metabolic acidosis in this scenario.

A. Moist mucous membranes: Moist mucous membranes are typically a sign of good hydration and are not usually associated with end-of-life stages. In fact, patients nearing the end of life often experience dryness of the mouth and mucous membranes due to decreased fluid intake and certain medications. This dryness can lead to discomfort and difficulties in swallowing or speaking, which is why oral care is an important part of end-of-life care.

B. Irregular respirations: This is correct. As the body’s systems start to shut down in the final stages of life, irregular respirations, including periods of rapid breathing and pauses (Cheyne-Stokes respirations), can be a common symptom. This happens because the body can no longer effectively remove carbon dioxide, and the automatic process of breathing becomes less coordinated. This can be distressing to witness, but it’s usually not uncomfortable for the patient.

C. Tachycardia: While some patients may experience changes in heart rate, tachycardia is not typically a consistent finding in patients at the end of life. As the body weakens, the heart has to work harder to pump blood, which can sometimes lead to a faster heart rate. However, as the end of life approaches, the heart rate often slows down, and blood pressure decreases.

D. Hypertension: Hypertension, or high blood pressure, is not typically a symptom associated with end-of-life care. In the final stages of life, the body’s systems begin to slow down, and blood pressure often decreases. This is due to a combination of factors, including a slower heart rate and a decrease in the body’s ability to regulate blood pressure. It’s also worth noting that pain, anxiety, and certain medications can temporarily increase blood pressure, even in the end-of-life stages.