A nurse is assisting in the care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action?
Perform immediate defibrillation.
Provide pulmonary ventilation.
Determine palpable pulse.
Begin chest compressions.
The Correct Answer is C
A. Perform immediate defibrillation: This is necessary for ventricular tachycardia with a pulse if it is unstable, but first, assess the client’s condition.
B. Provide pulmonary ventilation: This may be required depending on the client's breathing status but is secondary to assessing the pulse.
C. Determine palpable pulse: This is the priority action. Determining whether the client has a pulse helps guide the next steps—if the client has a pulse but is symptomatic, treatment will differ from if the client is pulseless.
D. Begin chest compressions: This is done if the client is pulseless. If there is a pulse, other interventions are needed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Glaucoma: Propranolol is not contraindicated in clients with glaucoma. It may, however, need to be used cautiously if the client has narrow-angle glaucoma due to potential systemic effects.
B. Asthma: This is correct as propranolol, a non-selective beta-blocker, can exacerbate asthma by causing bronchoconstriction, making it contraindicated in individuals with asthma.
C. Migraine headaches: Propranolol is often used to prevent migraine headaches and is not contraindicated in this condition. It is actually considered an effective treatment for migraine prophylaxis.
D. Irritable bowel syndrome: Propranolol is not contraindicated in irritable bowel syndrome. There are no specific concerns regarding propranolol's use with this condition.
Correct Answer is B
Explanation
A. Restrict fluid intake: This would not be appropriate for hypernatremia, as fluid intake should generally be increased to help dilute serum sodium levels.
B. Restrict sodium intake: This is correct as reducing sodium intake helps manage hypernatremia by decreasing the amount of sodium in the bloodstream.
C. Administer a potassium supplement: Potassium supplementation is not indicated for hypernatremia and could lead to imbalances.
D. Administer a laxative: A laxative is not relevant for managing hypernatremia and does not address the underlying issue of high sodium levels.
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