A nurse is caring for a client in the ICU who has a history of cardiac dysrhythmias. The client goes into a state of ventricular tachycardia, and the nurse is unable to find a pulse. The code team arrives and delivers a shock of defibrillation to the client at 150 Joules. Which step would the nurse perform next?

Choice A reason: Tongue furrows indicate dehydration but don’t assess ambulation safety, which requires hemodynamic stability. Orthostatic blood pressure changes are key, making this incorrect, as it’s less relevant than the nurse’s priority to evaluate fall risk in a dehydrated client.

Choice B reason: Comparing blood pressure in lying, sitting, and standing positions detects orthostatic hypotension, a fall risk in dehydrated older clients. This aligns with mobility safety assessment, making it the correct action to determine if the client is safe for independent ambulation.

Choice C reason: Serum potassium above 3.5 mEq/L ensures cardiac stability but doesn’t directly assess ambulation safety. Orthostatic changes are more relevant, making this incorrect, as it’s not the nurse’s primary focus for evaluating mobility in a dehydrated client.

Choice D reason: Radial and apical pulse consistency checks pacemaker function, not ambulation safety in dehydration. Blood pressure changes are critical, making this incorrect, as it’s unrelated to the nurse’s assessment of safe independent ambulation in the dehydrated older client.

Choice A reason: Monitoring temperature detects infection but is less urgent than ensuring airway safety post-endoscopy. Gag reflex assessment prevents aspiration, making this incorrect, as it’s secondary to the nurse’s priority of confirming safe swallowing after the procedure.

Choice B reason: Heartburn monitoring is relevant for ulcers but not the immediate post-endoscopy priority. Gag reflex return is critical, making this incorrect, as it’s less urgent than the nurse’s focus on airway protection after esophagogastroduodenoscopy in the client.

Choice C reason: Warm gargles soothe a sore throat but don’t address the risk of aspiration post-endoscopy. Assessing gag reflex is vital, making this incorrect, as it’s not the highest priority compared to the nurse’s focus on ensuring airway safety.

Choice D reason: Assessing the return of the gag reflex post-esophagogastroduodenoscopy is the highest priority to prevent aspiration due to sedation. This aligns with post-procedure safety, making it the correct item for the nurse to prioritize in the client’s care plan.