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.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Positioning the client supine may increase intracranial pressure. The client should be positioned with the head of the bed elevated to promote drainage and reduce pressure.
Choice B reason: The correct answer is b because changing the nasal drip pad as needed helps monitor for excessive drainage, cerebrospinal fluid leaks, and infection following pituitary gland removal.
Choice C reason: Frequent brushing of teeth should be avoided initially to prevent disruption of the surgical site and decrease the risk of infection. Gentle oral hygiene can be encouraged instead.
Choice D reason: Encouraging the client to cough every 2 hours can increase intracranial pressure and is not recommended following pituitary gland surgery. Deep breathing exercises without coughing are more appropriate.
Correct Answer is D
Explanation
Choice A reason: Placing tissue soiled with respiratory secretions in a paper bag for later disposal is not an appropriate infection control measure. Used tissues should be disposed of immediately in a proper waste receptacle to prevent the spread of tuberculosis bacteria.
Choice B reason: Sputum cultures should be provided more frequently than every 6 weeks to monitor the effectiveness of the treatment and to confirm when the client is no longer infectious. Monthly cultures are typically recommended until the patient shows no signs of active infection.
Choice C reason: Consuming alcohol in moderation while taking antituberculosis medications is not advised. Alcohol can interfere with the effectiveness of the medications and may also exacerbate potential side effects, such as liver toxicity, especially with medications like isoniazid and rifampin.
Choice D reason: The correct answer is d because wearing a mask while out or around crowds of people helps prevent the spread of tuberculosis. TB is an airborne disease, and wearing a mask reduces the risk of transmitting the infection to others.
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