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.

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Correct Answer is A

Explanation

A. A heart murmur typically indicates turbulent blood flow through a heart valve. This turbulence can occur due to various reasons, such as valve stenosis (narrowing), regurgitation (leakage), or structural abnormalities of the valves. The turbulent flow produces audible sounds that can be heard with a stethoscope during cardiac auscultation.

B. A heart murmur is not caused by blood entering an inflexible chamber. Instead, it is caused by turbulent blood flow through the heart valves. The sound produced by this turbulent flow may vary depending on the underlying pathology of the valve.

C. While heart murmurs can be described based on their characteristics (such as high-pitched or low- pitched), the presence of a heart murmur does not necessarily indicate a narrow valve. Murmurs can occur due to various valve abnormalities, including stenosis (narrowing) or regurgitation (leakage). The pitch and quality of the murmur may vary depending on the underlying pathology and the location of the abnormality.

D. A heart murmur is not typically associated with inflammation around the heart. While inflammation of the heart (such as myocarditis or pericarditis) can cause symptoms and abnormal sounds, these conditions would not be described specifically as a "heart murmur."

A. Hypokalemia B. Heart rate 160/min C. Mottled skin D. Blood pressure 115/68 mmHg

Correct Answer is B

Explanation

B. Tachycardia is a compensatory mechanism aimed at increasing cardiac output and maintaining tissue perfusion. In response to decreased perfusion, the body increases heart rate to improve circulation and oxygen delivery to tissues.
A. Hypokalemia, or low potassium levels, is not typically associated with the compensatory stage of shock. Instead, electrolyte imbalances may develop later in the progression of shock due to tissue hypoperfusion and metabolic disturbances.
C. Mottled skin, characterized by patchy discoloration due to uneven blood flow, is more commonly seen in the progressive or irreversible stages of shock. It indicates significant tissue hypoperfusion and impaired microcirculation, rather than the compensatory stage
D. This blood pressure reading is within the normal range and may be maintained during the compensatory stage of shock. Initially, blood pressure may be maintained or only slightly decreased due to compensatory mechanisms such as vasoconstriction. However, blood pressure can decrease further as shock progresses beyond the compensatory stage.

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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

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

Correct Answer is A

Explanation

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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