While assessing a patient in the CCU, the nurse observes the following rhythm on the monitor. The patient is alert and oriented and denies any complaints at present. The nurse should:
1. Administer a precordial thump.
2. Check lead placement on the patient.
3. Begin CPR and call for a defibrillator.
4. Administer epinephrine 1 mg IV every 3 minutes.
2
Rationale 1: A precordial thump should not be done.
Rationale 2: Even though the strip looks like asystole, the patient denies complaints and is not in distress and therefore is not in asystole. The most appropriate thing for the nurse to do is to check lead placement on the patient's chest.
Rationale 3: The patient is responsive and has respirations and a pulse. CPR and defibrillation is not indicated.
Rationale 4: This medication is not indicated for incorrect lead placement.
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