A client's electrocardiogram rhythm strip is a straight line. Which of the following should the nurse do to help this client? (Select all that apply.)
1. Assess for loose leads.
2. Assess for power to the monitor.
3. Assess the strip for possible fine ventricular fibrillation.
4. Begin cardiopulmonary resuscitation once verified the client has no pulse.
5. Raise the head of the bed.
6. Stop intravenous fluid infusion.
1, 2, 3, 4
The absence of electrical activity will create the rhythm of asystole. The rhythm strip is a straight line. The nurse should confirm that the straight line is not due to another reason such as loose leads, lack of power to the monitor, or fine ventricular fibrillation. Once it is confirmed that the client has no pulse, cardiopulmonary resuscitation should be implemented. Raising the head of the bed or stopping intravenous fluid infusions is not going to help the client experiencing asystole.
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