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 D
Explanation
A. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke": This is incorrect as glucocorticoids are not typically used to reduce stroke risk; they are more commonly used to manage inflammation and other conditions.
B. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke": This is incorrect because having a total cholesterol level below 200 mg/dL is generally considered desirable and lowers the risk of stroke.
C. "My risk for a stroke increases if my HbA1c level is 6 percent or less": This is incorrect because an HbA1c level of 6 percent or less is generally considered well-managed for diabetes and does not increase stroke risk; higher levels are more concerning.
D. "I can decrease my risk for a stroke by losing excess weight": This is correct as losing excess weight can reduce the risk of stroke by improving overall cardiovascular health and managing diabetes.
Correct Answer is B
Explanation
A. Restrict fluid intake: This would not be appropriate for hypernatremia, as fluid intake should generally be increased to help dilute serum sodium levels.
B. Restrict sodium intake: This is correct as reducing sodium intake helps manage hypernatremia by decreasing the amount of sodium in the bloodstream.
C. Administer a potassium supplement: Potassium supplementation is not indicated for hypernatremia and could lead to imbalances.
D. Administer a laxative: A laxative is not relevant for managing hypernatremia and does not address the underlying issue of high sodium levels.
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