A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
Amiodarone administration
Epinephrine administration
Defibrillation
Airway management
The Correct Answer is C
A. amiodarone is a medication used to treat ventricular fibrillation administered after defibrillation.
B. Epinephrine is also used in cardiac arrest, but it is administered after unsuccessful defibrillation attempts.
C. Defibrillation is the immediate life-saving intervention for ventricular fibrillation. It delivers a high- energy shock to the heart to try to restore normal rhythm.
D. While important in cardiac arrest, it is not the immediate priority. Defibrillation takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Spinal cord degeneration is a general term for the deterioration of the spinal cord and doesn't specifically describe the patient's posture.
B. Decorticate posturing is characterized by the arms flexed and adducted, with the wrists and fingers flexed. The legs are extended and adducted, with the feet plantar flexed.
C. Atypical hyperreflexia refers to exaggerated reflexes, not a specific posture.
D. Decerebrate posturing is characterized by the arms extended and pronated, with the wrists and fingers flexed. The legs are stiffly extended with plantar flexion.
Correct Answer is C
Explanation
A. There can be slight variations in pupil size but the difference described (one pupil enlarged and fixed, the other constricted and reactive to light) is not considered normal.
B. Age-related changes in pupil size typically involve a gradual decrease in pupil size, not a sudden and dramatic difference between the two eyes.
C. Unequal pupil size, especially when one pupil is fixed and dilated, is a classic sign of increased intracranial pressure (ICP), often caused by head trauma.
D. Exposure to light would cause both pupils to constrict, not one to dilate and fix.
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