When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?
Observe for swelling at the fracture site.
Analyze the cardiac rhythm in another lead.
Obtain a 12-lead electrocardiogram.
Begin chest compressions at 100/minute.
The Correct Answer is D
The correct answer is choice D: Begin chest compressions at 100/minute.
Choice A rationale:
Observing for swelling at the fracture site is not immediately relevant in this emergency situation. The priority is to address the lack of pulse and respiration.
Choice B rationale:
Analyzing the cardiac rhythm in another lead is unnecessary when the patient has no pulse and is not breathing. Immediate life-saving measures are required.
Choice C rationale:
Obtaining a 12-lead electrocardiogram is not the priority in this scenario. The patient needs immediate resuscitation efforts.
Choice D rationale:
Beginning chest compressions at 100/minute is the correct intervention. The absence of a carotid pulse and spontaneous respirations indicates cardiac arrest, and chest compressions are essential to maintain circulation and oxygenation until further help arrives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
To calculate the mL/hour for the erythromycin infusion, we first need to determine the infusion rate in mL/minute.
The infusion is to be completed over 30 minutes, which is equal to 0.5 hours. Next, we divide the total volume (100 mL) by the total time (0.5 hours) to get the infusion rate in mL/hour:
Infusion rate = Total volume / Total time
Infusion rate = 100 mL / 0.5 hours Infusion rate = 200 mL/hour
Therefore, the nurse should program the infusion pump to deliver the erythromycin infusion at a rate of 200 mL/hour.
Correct Answer is C
Explanation
Choice A rationale: Initiating the urine collection without reporting the low serum creatinine is inappropriate. A value of 0.3 mg/dL is below the reference range and may indicate significant muscle wasting or severe malnutrition.
Choice B rationale: Evaluating the BUN level provides information about hydration and renal perfusion, but it does not address the immediate clinical significance of an abnormally low creatinine level in an older adult client.
Choice C rationale: The nurse must notify the provider because a creatinine level of 0.3 mg/dL is abnormally low. In older adults, this often reflects low muscle mass, which significantly impacts how drug dosages are calculated.
Choice D rationale: Assessing for hypokalemia is not directly indicated by a low creatinine level. While electrolyte monitoring is important in drug toxicity, it is not the priority action linked to this specific lab finding.
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