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)
Provide chest compressions at a rate of 100/min.
Check for a brachial pulse.
After a set of 50 compressions, give the client 2 rescue breaths.
The Correct Answer is B
Choice A rationale:
While it’s important to start CPR as soon as possible, the AED should be attached as soon as it’s available.
Choice B rationale:
The American Heart Association recommends providing chest compressions at a rate of 100-120/min during CPR.
Choice C rationale:
Checking for a brachial pulse is not a priority during CPR. The focus should be on providing chest compressions and rescue breaths.
Choice D rationale:
The correct ratio of compressions to breaths during CPR is 30:2, not 50:2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
A client who has NPO (nothing by mouth) status since midnight for an endoscopy could be at risk for fluid volume deficit. NPO status means the client has not been able to consume fluids orally, which could lead to a decrease in fluid intake. However, the risk is relatively low if the NPO status has only been in place since midnight and the client is otherwise healthy.
Choice B rationale:
A client who has heart failure and is receiving diuretic therapy is at a high risk for fluid volume deficit. Diuretics are used in heart failure to remove excess fluid from the body, but they can also lead to fluid volume deficit if not properly managed. This is because diuretics increase urine output, which can lead to a loss of fluid and electrolytes.
Choice C rationale:
A client who has gastroenteritis and is receiving oral fluids is not typically at risk for fluid volume deficit. Gastroenteritis can cause fluid loss through diarrhea and vomiting, but if the client is able to consume and retain oral fluids, they can usually maintain their fluid balance.
Choice D rationale:
A client who has end-stage kidney disease and will undergo dialysis could be at risk for fluid volume deficit, but this risk is typically well-managed during dialysis. Dialysis removes waste and excess fluid from the blood, and fluid intake is carefully monitored and adjusted based on the individual’s needs. Therefore, while there is a potential risk, it is usually well-controlled under the care of healthcare professionals.
Correct Answer is ["1100"]
Explanation
The correct answer is 1100.
Calculation: The current time is 0700 and there are 300 mL remaining in the bag. The IV is infusing at a rate of 75 mL/hr. Therefore, 300 mL ÷ 75 mL/hr = 4 hours. Adding 4 hours to the current time of 0700 gives 1100.
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