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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Squamous cell carcinoma commonly occurs on sun-exposed areas such as the face, ears, neck, and hands, but not necessarily the trunk. It is important to emphasize the role of sun exposure in the development of this type of skin cancer.
Choice B reason: Radiation therapy is used in the treatment of certain types of skin cancer, but it is not typically the first choice for metastatic skin cancer. Other treatments, such as surgery, immunotherapy, or targeted therapy, are often preferred depending on the type and stage of skin cancer.
Choice C reason: The correct answer is c because sun exposure, especially during childhood, significantly increases the risk of developing skin cancer later in life. This highlights the importance of sun protection measures from an early age to prevent skin cancer.
Choice D reason: Basal cell carcinoma is the most common and least aggressive type of skin cancer. It rarely metastasizes and is usually slow-growing, making early detection and treatment highly effective.
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.
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