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.

Answer and Explanation

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.

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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.

A. Offer meals to the client following physical activity. B. Provide peanut butter on crackers as a snack choice. C. Provide liquids in a cup with a straw. D. Instruct the client to tilt his head forward when swallowing.

Correct Answer is D

Explanation

A. Offer meals to the client following physical activity: This is incorrect as eating after physical activity might be challenging for a client with dysphagia, and it is better to provide meals when the client is at rest.
B. Provide peanut butter on crackers as a snack choice: This is incorrect because peanut butter and crackers might be difficult to swallow and could pose a choking risk for someone with dysphagia.
C. Provide liquids in a cup with a straw: This is incorrect as straws can cause liquids to be aspirated more easily, which is a risk for clients with dysphagia.
D. Instruct the client to tilt his head forward when swallowing: This is correct because tilting the head forward can help prevent aspiration and facilitate safer swallowing in clients with dysphagia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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