A nurse is caring for a client who becomes unresponsive. While administering CPR, which of the following actions should the nurse take?

Complete two cycles of compression/rescue breathing before attaching the automated external defibrillator (AED).

Check for a brachial pulse.

Provide chest compressions at a rate of 100/min.

After a set of 50 compressions, give the client 2 rescue breaths.

Answer and Explanation

The Correct Answer is C

Choice A reason: While early CPR is crucial, the AED should be attached as soon as it is available to analyze the heart rhythm and provide a shock if needed. Delaying the use of the AED can reduce the chances of successful resuscitation.

Choice B reason: In adults, the carotid pulse is typically checked, not the brachial pulse. The brachial pulse is more commonly assessed in infants.

Choice C reason: The correct answer is c because providing chest compressions at a rate of 100-120 compressions per minute is the recommended rate for effective CPR. High-quality chest compressions are essential for maintaining circulation during cardiac arrest.

Choice D reason: The recommended ratio of chest compressions to rescue breaths is 30:2, not 50:2. Performing 50 compressions before providing rescue breaths is not aligned with current CPR guidelines.

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Correct Answer is B

Explanation

Choice A reason: While a healthy diet is important, avoiding fried foods alone is not sufficient for managing hepatitis A. This statement does not fully address the necessary precautions to prevent transmission.

Choice B reason: The correct answer is b because abstaining from sexual intercourse is essential to prevent the spread of hepatitis A. The virus can be transmitted through close personal contact, including sexual activity.

Choice C reason: Refraining from international travel may be advisable in some cases, but it is not a specific requirement for managing hepatitis A. This statement does not directly address transmission prevention.

Choice D reason: Avoiding salads in restaurants can help reduce the risk of foodborne transmission of hepatitis A, but it is not as comprehensive as abstaining from sexual intercourse, which directly prevents person-to-person transmission.

A. Insert an indwelling catheter to monitor for sediment in the urine. B. Take the client's temperature once per shift. C. Provide the client with fresh fruit to avoid constipation. D. Limit the number of health care workers entering the room.

Correct Answer is D

Explanation

Choice A reason: Inserting an indwelling catheter can increase the risk of urinary tract infections, which is particularly dangerous for immunosuppressed clients. Monitoring for sediment can be done through less invasive methods.

Choice B reason: Taking the client's temperature once per shift may not be frequent enough. More frequent monitoring is recommended to detect early signs of infection.

Choice C reason: Providing fresh fruit, while beneficial for preventing constipation, can pose an infection risk due to potential contamination. Alternatives like canned or cooked fruits should be considered.

Choice D reason: Limiting the number of health care workers entering the room reduces the risk of introducing infections to the immunosuppressed client. This is a key measure to protect clients with weakened immune systems.

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A nurse is caring for a client who becomes unresponsive. While administering CPR, which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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