The nurse on the unit hears an alarm sound in the client's room. Arriving in the room, the client is unresponsive. pulseless and the nurse sees the flat rhythm on the monitor. What is the FIRST action by the nurse?

Administer Atropine M

Defibrillate with 360 joules

Begin CPR

Administer Epinephrine N

Answer and Explanation

The Correct Answer is C

Choice A rationale: Atropine is not typically used in the treatment of cardiac arrest91011.

Choice B rationale: Defibrillation is not the first step in the treatment of cardiac arrest. The first step is to start CPR91011.

Choice C rationale: Starting CPR is the first action when a patient is unresponsive and pulseless91011.

Choice D rationale: While epinephrine is used in the treatment of cardiac arrest, it is not the first step. The first step is to start CPR91011.
So, the correct answer is Choice C, after analyzing all choices.

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Correct Answer is D

Explanation

The correct answer is choice D: Prepare to administer supplemental O2 via nasal cannula.

Choice A rationale:

Atropine is used to treat bradycardia (slow heart rate), not atrial flutter with a rapid heart rate. Administering Atropine in this scenario could potentially worsen the patient’s condition by increasing the heart rate further.

Choice B rationale:

While reassessing the patient’s blood pressure is important, it is not the most immediate action. The patient’s current blood pressure is stable (118/64), and the priority is addressing the low oxygen saturation and high respiratory rate, which indicates respiratory distress.

Choice C rationale:

Adenosine is used to treat certain types of supraventricular tachycardia by temporarily slowing the heart rate, but it is not the first-line treatment for atrial flutter. Additionally, the patient’s blood pressure is stable, and there is no indication of hemodynamic instability that would necessitate immediate rate control.

Choice D rationale:

The patient’s oxygen saturation is 90%, which is below the normal range, and they are tachypneic with a respiratory rate of 26 breaths per minute. The first action should be to administer supplemental oxygen to improve oxygenation and prevent hypoxemia-related complications. Oxygen therapy can help stabilize the patient’s condition and improve oxygen saturation levels.

A. Check the electrocardiogram (ECG) for ST segment changes. B. Assess for the presence of jugular venous distention (VD). C. Monitor for changes in the patient's sedimentation rate. D. Assess for the presence of a paradoxical pulse.

Correct Answer is B

Explanation

Choice A rationale: While changes in the ECG can indicate various heart conditions, they are not specific to the effectiveness of therapies for chronic constrictive pericarditis67.

Choice B rationale: Jugular venous distention is a common sign of chronic constrictive pericarditis, and its absence can indicate effective treatment67.

Choice C rationale: Changes in the sedimentation rate are not specific indicators of the effectiveness of therapies for chronic constrictive pericarditis67.

Choice D rationale: The presence of a paradoxical pulse is not a specific indicator of the effectiveness of therapies for chronic constrictive pericarditis67.
So, the correct answer is Choice B, after analyzing all choices.

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The nurse on the unit hears an alarm sound in the client's room. Arriving in the room, the client is unresponsive. pulseless and the nurse sees the flat rhythm on the monitor. What is the FIRST action by the nurse?

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Naxlex Comprehensive Predictor Exams

A patient on the telemetry unit develops atrial flutter with a heart rate of 150, respirations 26, b/p 118/64 and a o2 saturation of 90% while sitting down. Which action should the nurse do FIRST?

Correct Answer is D

Explanation

Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective?

Correct Answer is B

Explanation

A nurse is reviewing the EKG strip of a client who is hypotensive and is complaining of leg cramping. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

As the registered nurse, which tasks below should you NOT delegate to the LPN?

The nurse on the unit hears an alarm sound in the client's room. Arriving in the room, the client is unresponsive. pulseless and the nurse sees the flat rhythm on the monitor. What is the FIRST action by the nurse?

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