Chapter 10: Rapid Response Teams and Code Management

When doing manual ventilations during a code, the nurse would administer ventilations following which guideline? a. Approximately 8 to 10 breaths per minute b. During the fifth chest compression c. Every 3 seconds or 20 times per minute d. While compressions are stopped

ANS: A Manual ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.

The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest? a. Bag-valve-mask at FiO2 of 100% b. Bag-valve-mask at FiO2 of 50% c. Mouth-to-mask ventilation with supplemental oxygen d. Non-rebreather mask at FiO2 of 100%

ANS: A Oxygen can be delivered via mouth to mask or with a bag-valve device connected to a mask or endotracheal tube. During resuscitation efforts, 100% oxygen is administered.

A patient develops frequent ventricular ectopy. The nurse prepares to administer which drug? a. Adenosine b. Atropine c. Lidocaine d. Magnesium

ANS: C Lidocaine is an antidysrhythmic drug that suppresses ventricular ectopic activity.

The nurse needs to evaluate arterial blood gases before the administration of which drug? a. Calcium chloride b. Magnesium sulfate c. Potassium d. Sodium bicarbonate

ANS: D Bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit from arterial blood gas analysis or laboratory measurement.

During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex? a. P b. R c. S d. T

ANS: B During cardioversion, the electrical shock is synchronized to deliver shock on the R wave. This is to prevent the shock from being delivered during repolarization (T wave). Ventricular fibrillation may occur if the shock is delivered on the T wave.

The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which medication to administer to the patient? a. Adenosine b. Amiodarone c. Diltiazem d. Procainamide

ANS: A Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Adenosine has an onset of action of 10 to 40 seconds and duration of 1 to 2 minutes; therefore, it is administered rapidly.

The patient has pulseless electrical activity (PEA). What action by the nurse takes priority? a. Begin high-quality CPR. b. Assist with chest tube placement. c. Prepare equipment for a pericardiocentesis. d. Attach the patient to a transcutaneous pacemaker.

ANS: A A patient in PEA does not have a pulse or blood pressure. The nurse initiates high-quality CPR. Chest tube insertion, pericardiocentesis, and transcutaneous pacing are not required.

The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D, in which "D" refers to: a. defibrillate. b. differential diagnosis. c. diltiazem intravenous push. d. do not resuscitate.

ANS: B The A-B-C-D (airway, breathing, circulation, differential diagnosis) in the Advanced Cardiac Life Support (ACLS) secondary survey involves the performance of more in-depth assessments and interventions. Differential diagnosis involves investigation into the cause of the arrest. If a reversible cause is identified, a specific therapy can be initiated.

A nursing home patient is admitted to the critical care unit with a severe case of pneumonia. No living will or designation of health care surrogate is noted on the chart. In the event this patient needs intubation and/or cardiopulmonary resuscitation, what should be the nurse's action? a. Activate the code team, but initiate a "slow" code. b. Call the nursing home to determine the patient's or family's wishes. c. Code the patient for 5 minutes and then cease efforts. d. Initiate intubation and/or cardiopulmonary resuscitation efforts.

ANS: D In the absence of a written order from a physician to withhold resuscitative measures, resuscitation efforts must be initiated if indicated.

During a code situation, the nurse would prepare to use which preferred intravenous fluid? a. 5% dextrose in 0.45% normal saline b. 5% dextrose in water c. Dopamine infusion d. Normal saline

ANS: D Normal saline is the preferred intravenous fluid during resuscitation efforts because it expands intravascular volume better than infusions containing dextrose.

A patient is admitted to the coronary care unit with an inferior wall myocardial infarction and develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The nurse knows to prepare to administer which drug? a. Amiodarone b. Atropine c. Lidocaine d. Magnesium

ANS: B Atropine is used to increase the heart rate by decreasing the vagal tone. It is indicated for patients with symptomatic bradycardia.

The nurse should call the rapid response team for which patients? (Select all that apply) a. 53-year-old with pneumonia and severe respiratory distress b. 17-year-old with apnea following a severe head injury c. 24-year-old experiencing a severe asthmatic attack with stridor d. 73-year-old patient with bradycardia of 40 beats per minute e. 52-year-old patient with no palpable pulse

ANS: A, C, D Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patient's clinical condition before a cardiopulmonary arrest occurs. The patient without a pulse and the patient with apnea needs the code team activated.

The monitor technician notifies the nurse "stat" that the patient has a rapid, chaotic rhythm that looks like ventricular tachycardia. What is the nurse's first action? a. Call a code overhead. b. Check the patient immediately. c. Go to the nurses' station and look at the rhythm strip. d. Take the crash cart to the room.

ANS: B The first intervention in this situation is to assess unresponsiveness by checking the patient.

Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting? a. Automatic external defibrillator b. Carbon dioxide detector c. Pocket mask d. Transcutaneous pacemaker

ANS: A Because of the ease of use and efficacy in treating lethal ventricular dysrhythmias, automatic external defibrillators are recommended to be placed in a variety of public settings where they may be used by laypersons.

What is the major reason for using a treatment to lower body temperature after cardiac arrest to promote better neurological recovery? a. Hypothermia decreases the metabolic rate by 7% for each decrease of 1° C. b. Lower body temperatures are beneficial in patients with low blood pressure. c. Temperatures of 40° C may reduce neurological impairment. d. The lower body temperature leads to decreased oxygen delivery.

ANS: A Hypothermia decreases the metabolic rate by 6% to 7% for every decrease of 1° C in temperature; decreased metabolic rate may protect neurological function. Induced hypothermia to a core body temperature of 32° C to 34° C for 12 to 24 hours may be beneficial in reducing neurological impairment after cardiac arrest.

The patient's monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature ventricular contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which drug? a. Atropine 0.5 to 1 mg intravenous push b. Dopamine drip—continuous infusion c. Lidocaine 1 mg/kg intravenous push d. Transcutaneous pacemaker

ANS: A This patient is having PVCs secondary to bradycardia. Atropine is a first-line drug for bradycardia. Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg. Atropine is not indicated in second-degree atrioventricular (AV) block type II or third-degree AV block.

Postresuscitation goals include which of the following? (Select all that apply) a. Control dysrhythmias b. Maintain airway c. Maintain blood pressure d. Wean off oxygen e. Early ambulation

ANS: A, B, C Postresuscitation goals include optimizing tissue perfusion by airway, blood pressure maintenance, oxygenation, and control of dysrhythmias. Weaning off oxygen and early ambulation are good actions when possible but are not goals of postresuscitation care.

Which of the following are documented as part of the cardiopulmonary arrest record? (Select all that apply) a. Medication administration times b. Defibrillation times, joules, outcomes c. Rhythm strips of cardiac rhythm(s) noted d. Signatures of recorder and other personnel e. Model of defibrillator used.

ANS: A, B, C, D Documentation includes the time the code is called, the time CPR is started, any actions that are taken, and the patient's response (e.g., presence or absence of a pulse, heart rate, blood pressure, cardiac rhythm). Intubation and defibrillation (and the energy used) must be documented, along with the patient's response. The time and sites of IV initiations, types and amounts of fluids administered, and medications given to the patient must be accurately recorded. Rhythm strips are recorded to document events and response to treatment. Signatures of those involved in the code effort, including the recorder, are essential.

Benefits of having the family present during resuscitation include which of the following? (Select all that apply) a. Facilitates the grief process b. Lets the family see that everything is being done c. Sustains patient-family relationships d. Allows the staff easy access to ask for organ transplant e. Provides a sense of closure

ANS: A, B, C, E Families who have been present during a code describe the benefits as knowing that everything possible was being done for their loved one, feeling supportive and helpful to the patient and staff, sustaining patient-family relationships, providing a sense of closure on a life shared together, and facilitating the grief process.

Which of the following statements about defibrillation are correct? (Select all that apply) a. Early defibrillation (if warranted) is recommended before other actions. b. It is not necessary to ensure that personnel are clear of the patient if hands-off defibrillation is used. c. It is not necessary to synchronize the defibrillation shocks. d. Paddles/patches can be placed anteriorly and posteriorly on the chest. e. All models of defibrillators are the same for standardization.

ANS: A, C, D Defibrillation is indicated as soon as possible because early defibrillation and CPR increase the chance of survival. Regardless of the method of defibrillation, all personnel must avoid contact with the patient or bed during the shock delivery. Shocks are delivered without synchronization. Anterior paddle placement is used most often; however, the alternative method is anteroposterior placement. Defibrillators come in many models, and nurses must ensure they are familiar with the model in use on their unit.

A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent premature ventricular contractions. The nurse notes that the patient is lethargic and reports dizziness for the past 12 hours. Which of the following are acceptable initial treatments for this patient? (Select all that apply.) a. Atropine b. Epinephrine c. Lidocaine d. Transcutaneous pacemaker e. Magnesium sulfate infusion

ANS: A, D Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg for symptomatic bradycardia. Transcutaneous pacing is also indicated for symptomatic bradycardia unresponsive to atropine. Epinephrine infusion can be used if atropine is not effective but it is not a first-line choice. Lidocaine is contraindicated in bradycardia because it can depress conduction, which would be detrimental with a heart rate of 39 beats/min. Magnesium is not indicated for bradycardia.

It is determined that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be inserted. What is the most appropriate nursing intervention? a. Apply conductive gel to the skin. b. Provide adequate sedation and analgesia. c. Recheck leads to make sure that the rhythm is asystole. d. Set the milliamperes to 2 mA below the capture level.

ANS: B The alert patient who requires transcutaneous pacing may experience some discomfort. Because the skeletal muscles are stimulated, as well as the heart muscle, the patient may experience a tingling, twitching, or thumping feeling that ranges from mildly uncomfortable to intolerable. Sedation, analgesia, or both may be indicated.

A patient is brought to the critical care unit after a motor vehicle crash. On admission, the patient reports dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left side and a tracheal shift. The patient suddenly experiences cardiac arrest. What assessment by the nurse takes priority? a. Heart tones b. Lung sounds c. Peripheral pulses d. Neurological status

ANS: B The nurse should listen to lung sounds first. The signs and symptoms the patient experienced are consistent with a tension pneumothorax, which is a reversible cause of cardiac arrest. A tension pneumothorax occurs when air enters the pleural space but cannot escape. Pressure increases in the pleural space and causes the lung to collapse. Symptoms of a tension pneumothorax include dyspnea, chest pain, tachypnea, tachycardia, and jugular venous distension.

Which code drugs can be given safely through an endotracheal tube? (Select all that apply) a. Adenosine b. Atropine c. Epinephrine d. Vasopressin e. Amiodarone

ANS: B, C, D Medications that can be administered through the endotracheal tube until IV access is established are atropine, epinephrine, lidocaine, and vasopressin.

A patient has been successfully converted from ventricular tachycardia with a pulse to a sinus rhythm. Upon further assessment, it is noted that the patient is hypotensive. The appropriate treatment for her hypotension may include (Select all that apply) a. adenosine. b. dopamine infusion. c. magnesium. d. normal saline infusion. e. sodium bicarbonate.

ANS: B, D The patient may need fluid resuscitation; dopamine is indicated for hypotension once hypovolemia has been corrected. Adenosine, magnesium, and sodium bicarbonate are not indicated in this situation.

During a code, the nurse would place paddles for anterior defibrillation in what locations? a. Second intercostal space, left sternal border and fourth intercostal space, left midclavicular line b. Second intercostal space, right sternal border and fourth intercostal space, left midaxillary line c. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line d. Fourth intercostal space, right sternal border and fifth intercostal space, left midclavicular line

ANS: C Anterior paddle placement is used most often for defibrillation. In the anterior method, one paddle or adhesive electrode pad is placed at the second intercostal space to the right of the sternum, and the other paddle or adhesive electrode pad is placed at the fifth intercostal space, midaxillary line, to the left of the sternum.

The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2 minutes, what is the next action to take? a. Administer amiodarone. b. Administer lidocaine. c. Assess rhythm and pulse. d. Prepare for transcutaneous pacing.

ANS: C Reassess the patient frequently. Check for return of pulse, spontaneous respirations, and blood pressure.

The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the following? a. Obtain a 12-lead electrocardiogram (ECG). b. Call for a pacemaker interrogation. c. Palpate the pulse. d. Run a 2-minute monitor strip for analysis.

ANS: C The electrical and mechanical effectiveness of pacing is assessed. The electrical activity is noted by a pacemaker "spike" that indicates that the pacemaker is initiating electrical activity. The spike is followed by a broad QRS complex. Mechanical activity is noted by palpating a pulse during electrical activity.

The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction. Suddenly the monitor alarms and the screen shows a flat line. What action should the nurse take first? a. Administer epinephrine by intravenous push. b. Begin chest compressions. c. Check patient for unresponsiveness. d. Defibrillate at 360 J.

ANS: C The first intervention is to assess unresponsiveness

Which rhythm would be an emergency indication for the application of a transcutaneous pacemaker? a. Asystole b. Bradycardia (heart rate 40 beats/min), normotensive and alert c. Bradycardia (heart rate 50 beats/min) with hypotension and syncope d. Supraventricular tachycardia (heart rate 150 beats/min), hypotensive

ANS: C Transcutaneous (external noninvasive) cardiac pacing is used during emergencies to treat symptomatic bradycardia (hypotension, altered mental status, angina, pulmonary edema) that has not responded to atropine. This patient is symptomatic.

Ventricular fibrillation should initially be treated by which of the following? (Select all that apply) a. Administration of amiodarone, followed by defibrillation at 360 J b. Atropine 1 mg, followed by defibrillation at 200 J c. Defibrillation at 200 J with biphasic defibrillation d. Defibrillation at 360 J with monophasic defibrillation e. Dopamine continuous infusion.

ANS: C, D If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for terminating VF (typically 120 to 200 J). If the dose is not known, use 200 J. If a monophasic defibrillator is available, use an initial shock of 360 J and use 360 J for subsequent shocks. Dobutamine is used for hypotension not related to hypovolemia. Amiodarone can be used for ventricular fibrillation not responsive to CPR, defibrillation, and vasopressors. Atropine is not used in this situation.