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

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

A. Positive Kernig's sign:

Positive Kernig's sign is associated with meningitis, not thrombosis. It is a clinical sign where pain is elicited when the hip is flexed at a 90-degree angle and then the knee is extended. This sign is not relevant for identifying a thrombus.

B. Dull, aching calf pain:

Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT). Pain, swelling, and tenderness in the calf are typical manifestations of a thrombus in the leg veins. This symptom should alert the nurse to the possibility of a thrombus.

C. Soft, pliable calf muscle:

A soft, pliable calf muscle is not indicative of a thrombus. In the case of DVT, the affected leg is usually swollen, firm, and tender. Thus, this manifestation does not suggest the presence of a thrombus.

D. Positive Homan's sign:

Positive Homan's sign is identified when there is pain in the calf upon dorsiflexion of the foot. This sign can be indicative of DVT. Although not highly specific or sensitive, it is one of the traditional signs used to assess for the presence of a thrombus in the leg.

A. pH 7.48 B. pH 7.50 C. pH 7.31 D. pH 7.39

Correct Answer is C

Explanation

A. pH 7.48:

A pH of 7.48 indicates alkalosis, not acidosis. Respiratory acidosis is characterized by a pH below the normal range (7.35-7.45).

B. pH 7.50:

Similar to choice A, a pH of 7.50 indicates alkalosis, not acidosis.

C. pH 7.31:

This pH value falls below the normal range (7.35-7.45), indicating acidemia. In respiratory acidosis, there is an increase in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to an accumulation of carbonic acid and a decrease in pH.

D. pH 7.39:

A pH of 7.39 falls within the normal range (7.35-7.45), indicating a normal acid-base balance. It does not indicate acidosis.

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