A nurse is caring for a client who becomes unresponsive. While administering CPR, which of the following actions should the nurse take?

Complete two cycles of compression/rescue breathing before attaching the automated external defibrillator (AED).

Check for a brachial pulse.

Provide chest compressions at a rate of 100/min.

After a set of 50 compressions, give the client 2 rescue breaths.

Answer and Explanation

The Correct Answer is C

Choice A reason: While early CPR is crucial, the AED should be attached as soon as it is available to analyze the heart rhythm and provide a shock if needed. Delaying the use of the AED can reduce the chances of successful resuscitation.

Choice B reason: In adults, the carotid pulse is typically checked, not the brachial pulse. The brachial pulse is more commonly assessed in infants.

Choice C reason: The correct answer is c because providing chest compressions at a rate of 100-120 compressions per minute is the recommended rate for effective CPR. High-quality chest compressions are essential for maintaining circulation during cardiac arrest.

Choice D reason: The recommended ratio of chest compressions to rescue breaths is 30:2, not 50:2. Performing 50 compressions before providing rescue breaths is not aligned with current CPR guidelines.

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Correct Answer is B

Explanation

Choice A reason: Limiting fluid intake is not an appropriate intervention for labyrinthitis. Adequate hydration is important for overall health and should be maintained.

Choice B reason: The correct answer is b because labyrinthitis can affect the vestibular system, leading to dizziness and vertigo. Monitoring the client’s cardinal fields of vision helps assess for nystagmus, which is a common symptom of vestibular disorders.

Choice C reason: Encouraging ambulation is not advisable for clients with labyrinthitis, as it can increase the risk of falls and injury due to dizziness and imbalance.

Choice D reason: Ensuring the room is brightly lit is not necessary for the management of labyrinthitis and may not provide any therapeutic benefit.

A. "I can experience harmless, black-colored stools while taking this medication." B. "I will eat a low-potassium diet while taking this medication." C. "I will protect my adrenal glands by taking this medication every other day." D. "I can achieve the best effectiveness by taking this medication before bedtime."

Correct Answer is C

Explanation

Choice A reason: Black-colored stools can indicate gastrointestinal bleeding, which is a potential side effect of corticosteroids like betamethasone. It is not considered harmless and should be reported to the healthcare provider immediately.

Choice B reason: A low-potassium diet is not specifically required for clients taking betamethasone. Corticosteroids can cause potassium loss, so it is important to monitor potassium levels, but not necessarily restrict intake unless directed by the healthcare provider.

Choice C reason: The correct answer is c because taking corticosteroids like betamethasone every other day can help reduce the risk of adrenal suppression, a common side effect of long-term corticosteroid use. This dosing schedule allows the adrenal glands to recover and maintain their function.

Choice D reason: Taking betamethasone before bedtime is not specifically recommended for its effectiveness. The dosing schedule should be based on the healthcare provider's instructions and tailored to the client's condition and response to the medication.

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A nurse is caring for a client who becomes unresponsive. While administering CPR, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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