Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?
Initiate cardiopulmonary resuscitation (CPR).
Establish intravenous (IV) access.
Carry out immediate defibrillation.
Check the client’s latest electrolyte levels.
The Correct Answer is C
The correct answer is choice c. Carry out immediate defibrillation.
Choice A rationale:
Initiating cardiopulmonary resuscitation (CPR) is essential for a client who is unresponsive and without a pulse. However, in the presence of ventricular fibrillation, immediate defibrillation is the priority to restore a viable heart rhythm.
Choice B rationale:
Establishing intravenous (IV) access is important for administering medications during resuscitation. However, it is not the immediate priority when defibrillation is indicated.
Choice C rationale:
Immediate defibrillation is the priority action for a client with ventricular fibrillation who is unresponsive and without a pulse. Defibrillation can quickly restore a normal heart rhythm, which is critical in saving the client’s life.
Choice D rationale:
Checking the client’s latest electrolyte levels can provide valuable information for ongoing treatment but is not the immediate priority in an emergency situation where defibrillation is indicated. Immediate action to restore the heart rhythm is more critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Weight loss is often recommended as a first-line therapeutic approach to lowering blood pressure in patients diagnosed with essential hypertension. Excess weight can increase the strain on the heart and blood vessels, leading to higher blood pressure.
Choice B rationale
Regular physical activity is another important part of managing hypertension. Exercise can help lower blood pressure by improving heart health and reducing weight.
Choice C rationale
Beta-blockers, such as propranolol, are a type of medication used to treat hypertension. However, they are not typically the first choice for initial therapy unless the patient has a specific indication for this class of medication, such as heart failure or angina.
Choice D rationale
Decreasing sodium intake is another lifestyle change that can help lower blood pressure. Consuming too much sodium can cause the body to retain fluid, which can increase blood pressure.
Choice E rationale
Smoking cessation is also recommended for patients with hypertension. While smoking does not directly cause high blood pressure, it can damage blood vessels and increase the risk of heart disease.
Correct Answer is D
Explanation
Choice A rationale
Serum hemoglobin of 14.7 g/dL is within the normal range for adults, which is typically 12.0 to
16.0 g/dL for women and 13.5 to 17.5 g/dL for men. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. While it’s important to monitor hemoglobin levels, a value of 14.7 g/dL does not raise immediate concerns related to hypertension.
Choice B rationale
A blood glucose level of 96 mg/dL is considered normal. The normal range for fasting blood glucose is between 70 and 100 mg/dL1. Blood glucose levels are important to monitor, especially in patients with diabetes, but a value of 96 mg/dL is not immediately concerning in the context of hypertension.
Choice C rationale
A serum potassium level of 4.5 mEq/L is within the normal range, which is typically 3.6 to 5.2 mEq/L1. Potassium is an essential electrolyte that helps regulate heart and muscle contractions and maintain fluid balance in the body. While it’s important to monitor potassium levels, a value of 4.5 mEq/L does not raise immediate concerns related to hypertension.
Choice D rationale
A serum creatinine level of 2.8 mg/dL is high. Creatinine is a waste product that’s produced by your muscles and filtered out of your blood by your kidneys. High levels of creatinine can indicate that the kidneys aren’t working properly, which can be a complication of hypertension. Therefore, this result is the most important to communicate to the healthcare provider.
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