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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ammonia 55 mcg/dL (10 to 80 mcg/dL): This value is within the normal range and does not indicate an immediate concern for a liver biopsy.
B. Platelets 60,000/mm³ (150,000 to 400,000/mm³): This value is significantly below the normal range and indicates thrombocytopenia, which increases the risk of bleeding during a liver biopsy and should be reported to the provider.
C. Aspartate aminotransferase 34 units/L (0 to 34 units/L): This value is on the upper limit of normal and generally does not require reporting unless there are other clinical concerns.
D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL): This value is at the upper limit of normal and does not require reporting unless there are additional symptoms or concerns.
Correct Answer is A
Explanation
A. Participate in reminiscence therapy with the client: This is correct as reminiscence therapy, which involves discussing past experiences and memories, can help improve mood and cognitive function in clients with Alzheimer's disease.
B. Alternate the client's daily routine: Consistency is important for clients with Alzheimer's disease to reduce confusion and anxiety. Alternating the routine can be disorienting.
C. Keep the lights dimmed: Keeping the lights dimmed can contribute to confusion and disorientation. Adequate lighting is essential for safety and to help the client maintain a clear sense of time and space.
D. Raise the four side rails on the client's bed: Raising all four side rails can be considered a form of restraint and is not recommended. It can increase the risk of injury and does not address the client's needs appropriately.
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