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 D
Explanation
Choice A rationale:
Increased deep tendon reflexes are not typically associated with anaphylaxis. This is more commonly seen in conditions affecting the nervous system.
Choice B rationale:
While erythema of the skin can occur in anaphylaxis, it is not the most indicative symptom of this condition.
Choice C rationale:
Bradycardia is not typically associated with anaphylaxis. Anaphylaxis is more likely to cause tachycardia, or a rapid heart rate.
Choice D rationale:
Hypotension, or low blood pressure, is a common symptom of anaphylaxis. This occurs due to widespread vasodilation in response to the allergen.
Correct Answer is A
Explanation
Choice A rationale:
Asking the client’s full name and date of birth is the most reliable method of identification.
Choice B rationale:
Verifying the client’s room number is not reliable because room assignments can change.
Choice C rationale:
Asking a family member to verify the client’s identity is not always possible or reliable.
Choice D rationale:
Checking the client’s name on the medication administration record (MAR) is important but should be done in conjunction with direct client identification.
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