The rapid response team (RRT) is caring for a client with asystole. Which nursing statement made to the client's family about the actions of the RRT is appropriate?

The rapid response team will begin with defibrillation and then progress to cardiopulmonary resuscitation if needed

It would be best if you waited outside, as you won't want to see cardiopulmonary resuscitation performed on your loved one

As long as the team is doing cardiopulmonary resuscitation, your loved on has a normal blood flow throughout their body

The rapid response team cannot defibrillate your loved on because they are in systole; they are continuing cardiopulmonary resuscitation.

Answer and Explanation

The Correct Answer is D

D. Asystole represents the absence of electrical activity in the heart and is not amenable to defibrillation. Therefore, the RRT would continue cardiopulmonary resuscitation (CPR) with chest compressions and may administer medications or other interventions as indicated. This statement provides accurate information to the family about the patient's condition and the actions being taken by the RRT.

A. Defibrillation is not indicated for asystole. Asystole represents a flatline on the cardiac monitor, indicating the absence of electrical activity in the heart. Defibrillation is only effective for certain types of cardiac rhythms, such as ventricular fibrillation or pulseless ventricular tachycardia. Therefore, the RRT would not use defibrillation for a patient in asystole.

B. It does not provide the family with information about the patient's condition or the actions being taken by the RRT. Moreover, excluding the family from the patient's care may cause additional distress and prevent them from being present to support their loved one during a critical situation.

C. Cardiopulmonary resuscitation (CPR) is performed to maintain blood flow and oxygenation to vital organs during cardiac arrest. However, it does not restore normal blood flow or circulation. The goal of CPR is to provide temporary support until advanced interventions can be initiated or until return of spontaneous circulation (ROSC) is achieved.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Positive end-expiratory pressure (PEEP) is applied during mechanical ventilation to prevent alveolar collapse at the end of expiration. It helps maintain the patency of the alveoli, improving oxygenation and preventing atelectasis.
B. While PEEP can improve oxygenation by recruiting collapsed alveoli and increasing functional residual capacity, it does not directly affect the concentration of oxygen delivered by the ventilator. Oxygen concentration is adjusted separately from PEEP settings.
C. PEEP is applied at the end of expiration to maintain positive pressure in the airways and alveoli, preventing them from collapsing. It does not directly affect the delivery of air during inhalation.
D. PEEP can help prevent lung damage by maintaining alveolar recruitment and reducing the risk of atelectasis and barotrauma. However, it is not the sole factor in preventing lung damage, and other ventilator settings and strategies also play a role in protecting the lungs.

A. Respiratory rate 22 breaths/min B. Heart rate 106 beats/min C. 02 saturation of 99% D. Crackles audible at lung bases

Correct Answer is D

Explanation

D Crackles audible at the lung bases indicate the presence of pulmonary edema or fluid accumulation in the alveoli, which can compromise gas exchange and exacerbate respiratory distress. In a patient with ARDS, crackles suggest worsening pulmonary status and may indicate inadequate ventilation or oxygenation despite mechanical ventilation. Therefore, crackles at the lung bases are the most important finding to report to the healthcare provider as they may indicate a need for adjustments to the ventilator settings or additional interventions to optimize respiratory function and prevent further deterioration.

A respiratory rate of 22 breaths/min may be within an acceptable range, particularly considering that the patient is receiving mechanical ventilation. However, any significant deviation from the baseline respiratory rate or signs of respiratory distress, such as increased work of breathing or accessory muscle use, should be closely monitored and reported promptly.

B A heart rate of 106 beats/min may be within an acceptable range, although it is slightly elevated. Tachycardia can occur due to various factors, including pain, anxiety, fever, or hypoxemia. While tachycardia warrants close monitoring, it may not be the most critical finding to report unless it is associated with hemodynamic instability or other concerning symptoms.

C An oxygen saturation of 99% indicates adequate oxygenation, which is reassuring, particularly in a patient with acute respiratory distress syndrome (ARDS). However, oxygen saturation alone may not reflect the adequacy of ventilation or the severity of the underlying lung injury. Therefore, while oxygen saturation should be monitored closely, it may not be the most critical finding to report unless it declines significantly or is accompanied by other concerning symptoms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The rapid response team (RRT) is caring for a client with asystole. Which nursing statement made to the client's family about the actions of the RRT is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

The nurse is caring for a client with a history of heart failure and notes a new onset of the following rhythm on the client's telemetry monitor. Which action would the nurse take first?

Which of the following medications is commonly used for afterload reduction in critical care?

A patient with respiratory failure has a respiratory rate of 26 breaths/min and an oxygen saturation (SpO2) of 80%. The patient is increasingly pale and restless but follows commands. Which intervention will the nurse anticipate?

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. What procedure should the nurse anticipate assisting with to determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure?

An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?