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 C
Explanation
A. Elevate the head of the bed 45° before starting the CPM device: This is incorrect as elevating the head of the bed is not a necessary preparation for using the CPM device. The device should be used according to the specific postoperative guidelines.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect because the frame joint should generally be in an extended position to properly align the leg for movement through the device's range of motion.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct because proper alignment of the knee joint with the CPM device's frame joint is crucial to ensure that the device functions correctly and promotes effective range-of-motion exercises.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect because the degree of flexion should be adjusted according to the prescribed protocol by the healthcare provider and should not be self-adjusted by the client.
Correct Answer is D
Explanation
A. Pork sausage with sautéed peppers: Pork sausage is typically high in sodium and saturated fats, which can contribute to increased blood pressure.
B. Beef bouillon with crackers: Beef bouillon is high in sodium, which can elevate blood pressure, making it an unsuitable choice for someone with hypertension.
C. A ham sandwich on rye bread: Ham is high in sodium, and consuming it can negatively impact blood pressure control.
D. Broiled cod with broccoli: This is correct as both broiled cod and broccoli are low in sodium and beneficial for blood pressure control. This choice aligns with dietary recommendations for managing hypertension.
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