A client is complaining of severe chest pain became unresponsive and the cardiac monitor shows the heart rhythm below. What will be the most appropriate action
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
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Prepare for defibrillation: The client is unresponsive and has ventricular tachycardia. This indicates a life-threatening arrhythmia. If a patient with VTach is pulseless, the treatment is defibrillation.
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Vtach (Ventricular tachycardia): The ECG tracing shows a rapid, wide-complex tachycardia, which is the hallmark of ventricular tachycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Discontinuing the tube feeding and transitioning to parenteral nutrition is not the first action, as the residual volume may be manageable with additional interventions.
B. A residual volume of 200 mL is above the usual threshold, so the nurse should stop the feeding, wait, and recheck the residual to assess if it improves.
C. While positioning can help gastric emptying, the immediate action should be to stop the feeding and reassess before continuing.
D. Continuing the feeding without rechecking the residual volume would be premature, as the volume is higher than expected, potentially increasing the risk of aspiration.
Correct Answer is ["C","E"]
Explanation
A. Elevating the site is incorrect because in crush injuries, elevation can worsen ischemia by reducing arterial perfusion.
B. Performing a fasciotomy is incorrect because this is a surgical procedure that must be performed by a physician when compartment syndrome is diagnosed.
C. Applying a clean dressing to protect the wound is correct as it prevents contamination and infection.
D. Inserting an indwelling catheter is incorrect unless there is concern for shock or fluid balance issues, which are not immediately indicated in the question.
E. Splinting the wound in a position of rest to prevent motion is correct as immobilization reduces pain and prevents further injury.
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