A nurse is assisting in the care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action?
Perform immediate defibrillation.
Provide pulmonary ventilation.
Determine palpable pulse.
Begin chest compressions.
The Correct Answer is C
A. Perform immediate defibrillation: This is necessary for ventricular tachycardia with a pulse if it is unstable, but first, assess the client’s condition.
B. Provide pulmonary ventilation: This may be required depending on the client's breathing status but is secondary to assessing the pulse.
C. Determine palpable pulse: This is the priority action. Determining whether the client has a pulse helps guide the next steps—if the client has a pulse but is symptomatic, treatment will differ from if the client is pulseless.
D. Begin chest compressions: This is done if the client is pulseless. If there is a pulse, other interventions are needed first.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. Perform immediate defibrillation: This is necessary for ventricular tachycardia with a pulse if it is unstable, but first, assess the client’s condition.
B. Provide pulmonary ventilation: This may be required depending on the client's breathing status but is secondary to assessing the pulse.
C. Determine palpable pulse: This is the priority action. Determining whether the client has a pulse helps guide the next steps—if the client has a pulse but is symptomatic, treatment will differ from if the client is pulseless.
D. Begin chest compressions: This is done if the client is pulseless. If there is a pulse, other interventions are needed first.
Correct Answer is C
Explanation
A. Intermittent abdominal pain: While abdominal pain may occur, it is not specifically related to total parenteral nutrition (TPN) and burn care.
B. Decreased calcium levels: Decreased calcium levels are not the primary concern with TPN. Calcium levels should be monitored, but other issues are more directly related to TPN.
C. Increased serum glucose levels: This is correct as TPN often contains high levels of glucose, which can lead to hyperglycemia. Monitoring serum glucose levels is crucial in managing TPN to avoid complications.
D. Absent bowel sounds: Bowel sounds are not directly affected by TPN. However, monitoring for gastrointestinal function is important in the overall assessment of the client.
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