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: 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.

A. Limit fluid intake. B. Monitor client’s cardinal fields of vision. C. Encourage ambulation. D. Ensure the room is brightly lit.

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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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 assisting in the plan of care for a client who had a removal of the pituitary gland. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

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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