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 B
Explanation
Choice A reason: Rubbing the client's feet briskly can increase circulation temporarily, but it may also cause discomfort or irritation, especially if the client has compromised vascular health.
Choice B reason: The correct answer is b because obtaining a pair of slipper socks for the client can help keep the feet warm and improve comfort. Warm socks are a non-invasive and safe way to address the client's complaint of cold feet.
Choice C reason: Increasing the client's oral fluid intake is important for overall health, but it is not a direct solution for addressing cold feet due to vascular occlusion.
Choice D reason: Placing a moist heating pad under the client's feet can be risky, especially for clients with vascular issues, as it can lead to burns or skin damage. Dry heat, if used, should be carefully monitored to avoid injury.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Osteoarthritis is a degenerative joint disease and is not associated with SIADH. It does not typically affect the body's regulation of antidiuretic hormone (ADH) or fluid balance.
Choice B reason: Lung cancer, particularly small cell lung cancer, is a common cause of SIADH. Tumor cells can produce and secrete ADH, leading to inappropriate water retention and hyponatremia. Therefore, asking about lung cancer history is important in the assessment.
Choice C reason: The correct answer is c because liver cirrhosis can lead to secondary conditions that may affect fluid balance and ADH secretion. Although not a direct cause of SIADH, liver dysfunction can complicate the clinical picture and contribute to fluid retention issues.
Choice D reason: Dyspepsia, or indigestion, is not related to SIADH and does not typically impact ADH regulation. It is a gastrointestinal issue that does not affect fluid balance.
Choice E reason: The correct answer is e because seizures can be associated with conditions that trigger SIADH. Neurological disorders, including brain injuries and infections, can lead to the inappropriate release of ADH, resulting in fluid retention and hyponatremia.
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