The nurse is supervising a graduate nurse (GN) on a telemetry unit. An assigned client develops asystole with no pulse, and emergency care interventions are initiated. Which action by the GN would cause the supervising nurse to intervene?

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11ecbb05_cafc_8595_b433_2388185fb1fb_MD0009_00 The client in asystole has a total absence of ventricular electrical activity and is pulseless, apneic, and unresponsive. The nurse should first verify the monitor reading by assessing the client and palpating for a pulse, and then call for help and initiate emergency care (ie, CPR, oxygenated ventilation). Defibrillation is not indicated when there is no electrical activity present (ie, asystole) or when the heart muscle is not contracting despite an organized rhythm (ie, pulseless electrical activity [PEA]). Defibrillation attempts to convert lethal ventricular dysrhythmias (ie, ventricular fibrillation and pulseless ventricular tachycardia) into an organized rhythm by passing an electric shock through the heart. Defibrillation cannot create an organized rhythm if there is no electrical activity in the heart (Option D). (Options A, B, and C) Immediate interventions for asystole and PEA include CPR and oxygenated ventilation. Advanced cardiovascular life-support measures include epinephrine IV, placement of advanced airway (ie, intubation), and treatment of reversible causes (eg, hypovolemia, hyperkalemia). When treating asystole or PEA, the absolute priority is providing continuous, high-quality CPR and oxygenated ventilation until circulation spontaneously returns or the client enters into a shockable rhythm. Unfortunately, restoration of circulation may not be possible, and clients in asystole often cannot be resuscitated. Educational objective: Asystole is characterized by a total absence of ventricular electrical activity. The client is pulseless, apneic, and unresponsive. Treatment includes CPR, oxygenated ventilation, and advanced cardiovascular life-support measures (eg, epinephrine IV, advanced airway). Defibrillation is not effective for treatment of asystole or pulseless electrical activity.

The Nurse Is Supervising a Graduate Nurse (GN) on a Telemetry