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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale
Orthostatic hypotension, a form of low blood pressure that happens when you stand up from sitting or lying down, would not typically cause severe chest pain or result in elevated levels of cardiac troponins I and T6.
Choice B rationale
Raynaud’s disease, a condition that causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress, would not typically cause severe chest pain or result in elevated levels of cardiac troponins I and T6.
Choice C rationale
Angina, a type of chest pain caused by reduced blood flow to the heart, could cause severe chest pain, but it would not typically result in elevated levels of cardiac troponins I and T6. Elevated troponin levels are more indicative of damage to the heart muscle, which is not characteristic of angina.
Choice D rationale
A myocardial infarction (MI), also known as a heart attack, could cause severe chest pain and would typically result in elevated levels of cardiac troponins I and T7. Troponins are proteins found in the heart muscle, and levels can rise in the blood when there is damage to the heart, such as during an MI.

A. Newly admitted patient with a BP of 150/87 mm Hg. B. Patient with left ventricular failure who has a BP of 110/70 mm Hg. C. Postoperative patient with a BP of 116/42 mm Hg. D. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.

Correct Answer is C

Explanation

The patient with a blood pressure of 116/42 mm Hg has a mean arterial pressure (MAP) of approximately 67 mm Hg, which is less than the standard policy of 70 mm Hg. This could indicate inadequate blood flow to the vital organs, necessitating notification of the healthcare provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 75-year-old male experiences severe chest pain and calls 911. Given that lab findings indicate elevated levels of cardiac troponins I and T, what condition does the nurse suspect?

Correct Answer is D

Explanation

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Correct Answer is C

Explanation

Coarctation of the aorta refers to the local narrowing of the aorta near which location?

A woman has recently been diagnosed with Raynaud’s disease. What important information should the nurse provide to this patient?

When preparing a patient for a cardiac catheterization and coronary angiogram, which piece of information about the patient is crucial for the nurse to relay to the healthcare provider prior to the procedure?

What is included in the first-line therapeutic approach to lowering blood pressure in a patient diagnosed with essential hypertension? (Select all that apply)

A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?

As a nurse in a community-based setting, you are educating clients on strategies to prevent cardiovascular disease. Which interventions should you include? (Select all that apply)

A newborn frequently experiences cyanosis, typically during crying or after feeding. Which cardiac diagnosis is supported by this history?

What nursing assessment finding would suggest inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome (myocardial infarction)?