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 A
Explanation
A. Mark the edges of steps: Marking the edges of steps with high-contrast tape or paint helps increase visibility and prevent falls for individuals with visual impairments.
B. Use low-wattage light bulbs: Using low-wattage light bulbs might reduce the brightness needed for safety. Higher-wattage bulbs or bright, energy-efficient lighting is usually recommended to improve visibility.
C. Place throw rugs over electrical cords: Placing throw rugs over electrical cords can create tripping hazards and is not a safe practice for individuals with visual impairments.
D. Leave doors slightly ajar: Leaving doors ajar can create obstacles and increase the risk of injury for someone with visual impairment, as they may not be able to detect the open door.
Correct Answer is B
Explanation
A. Eat lighter, low-calorie foods first: While light foods can be easier to consume, prioritizing low-calorie foods may not address the client's nutritional needs. The focus should be on high-calorie, high-protein foods to maintain weight and strength.
B. Limit fluid intake during meals: This is correct as limiting fluid intake during meals can help prevent bloating and early satiety, which can be an issue for clients with COPD who have reduced appetite.
C. Eliminate dairy products: There is no general indication to eliminate dairy products unless the client has a specific intolerance or allergy. Dairy products are not universally problematic for clients with COPD.
D. Consume three regular meals daily: Clients with COPD may benefit from smaller, more frequent meals rather than three large meals to prevent feelings of fullness that can reduce appetite and increase shortness of breath.
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