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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Related Questions
Correct Answer is D
Explanation
A. A client who has Alzheimer's disease and requires assistance to the bathroom: This is important but less urgent compared to the risk of worsening condition in a client with a decreased level of consciousness.
B. A client who has diverticulitis and a temperature of 38.3° C (100.9° F): This is a concern, but it is not as immediately critical as a decreased level of consciousness, which may indicate a more severe underlying issue.
C. A client who has a prescription for a sputum specimen to be obtained before breakfast: While important for diagnostic purposes, this is less urgent compared to a decreased level of consciousness.
D. A client who sustained a head injury 2 days ago and has a decreased level of consciousness: This is correct because a decreased level of consciousness in a client with a recent head injury could indicate a serious complication, such as increased intracranial pressure or worsening of their condition, requiring immediate assessment and intervention.
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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