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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pork sausage with sautéed peppers: Pork sausage is typically high in sodium and saturated fats, which can contribute to increased blood pressure.
B. Beef bouillon with crackers: Beef bouillon is high in sodium, which can elevate blood pressure, making it an unsuitable choice for someone with hypertension.
C. A ham sandwich on rye bread: Ham is high in sodium, and consuming it can negatively impact blood pressure control.
D. Broiled cod with broccoli: This is correct as both broiled cod and broccoli are low in sodium and beneficial for blood pressure control. This choice aligns with dietary recommendations for managing hypertension.
Correct Answer is A
Explanation
A. Changed mental status: This is a common indicator of a bladder infection in older adults, who may present with confusion or altered mental status instead of classic symptoms like dysuria or frequency.
B. WBC count 9,000/mm³ (5000 to 10,000/mm³): This WBC count is within the normal range and does not specifically indicate a bladder infection.
C. Diminished reflexes: This is not a typical indicator of a bladder infection and may suggest other neurological issues.
D. Temperature 37.3° C (99.1° F): This temperature is within the normal range and does not suggest an infection unless elevated or accompanied by other symptoms.
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