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 D
Explanation
A. "My urine comes out whenever I sneeze": This indicates stress incontinence, where urine leakage occurs with physical activities that increase abdominal pressure.
B. "It seems like my bladder empties without warning": This suggests urge incontinence, characterized by a sudden and intense urge to urinate.
C. "I have urine incontinence whenever I take a diuretic": This statement is more related to the effects of diuretics rather than a specific type of urinary incontinence.
D. "My urine seems to dribble out frequently": This is characteristic of overflow incontinence, where the bladder becomes overfilled and urine dribbles out due to inadequate emptying.
Correct Answer is C
Explanation
A. "Knee-high stockings can be rolled down slightly to provide comfort": Rolling down antiembolic stockings can cause bunching and reduce their effectiveness in preventing deep vein thrombosis. They should fit smoothly without rolling.
B. "I should flex my toes when applying the stockings": To apply the stockings, the toes should be pointed or relaxed, not flexed, to ensure proper application and avoid discomfort.
C. "The thigh-high stockings should reach just above the gluteal folds": This is correct as thigh-high stockings should extend to just above the gluteal folds to ensure proper fit and effectiveness in preventing blood clots.
D. "I should reapply the stockings before I get out of bed": Antiembolic stockings are typically applied in the morning after getting out of bed and should remain on throughout the day. Reapplying before getting out of bed is not necessary.
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