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 D
Explanation
A. Limit physical activity until bladder continence is achieved: Limiting physical activity is not recommended and can impact overall health. Encouraging regular activity may help improve bladder function and overall well-being.
B. Encourage the client to contract the abdominal muscles when they experience the urge to void: Contracting the abdominal muscles is not typically recommended for managing incontinence. The focus should be on bladder training and strengthening the pelvic floor muscles.
C. Instruct the client to void as soon as they feel the urge: This approach may not support bladder training, which aims to increase the time between voids to improve bladder control.
D. Instruct the client to void at scheduled times throughout the day: This is correct as scheduled voiding helps retrain the bladder, gradually increasing the intervals between voids and improving continence.
Correct Answer is A
Explanation
A. "Consume vitamin D supplements daily": This is correct as vitamin D is crucial for calcium absorption and bone health, which helps in preventing osteoporosis.
B. "Obtain an x-ray of your growth plate every 6 months": This is not necessary for osteoporosis prevention. Growth plates are relevant in children and adolescents, not in older adults.
C. "Decrease vitamin K in your diet": Vitamin K is important for bone health and should not be decreased. It plays a role in bone mineralization and should be included in a balanced diet.
D. "Engage in passive range-of-motion exercises": Active weight-bearing exercises are more beneficial for preventing osteoporosis. Passive range-of-motion exercises do not provide the same benefits for bone density and strength.
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