A nurse is caring for a client who is found unresponsive and pulseless in their room. An ECG confirms the client is in pulseless ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Defibrillation

Vagal maneuvers

Radiofrequency catheter ablation

Administration of Atropine

Answer and Explanation

The Correct Answer is A

Choice A reason: Defibrillation is the appropriate intervention for pulseless ventricular tachycardia (VT). It delivers an electrical shock to the heart to restore a normal rhythm. Immediate defibrillation is crucial for survival as it can terminate the arrhythmia and allow the heart to re-establish an effective rhythm.

Choice B reason: Vagal maneuvers, such as the Valsalva maneuver, are used to terminate supraventricular tachycardias but are ineffective for pulseless VT. These maneuvers stimulate the vagus nerve to slow the heart rate but do not provide the necessary intervention for life-threatening arrhythmias like pulseless VT.

Choice C reason: Radiofrequency catheter ablation is a procedure used to treat recurrent arrhythmias by destroying abnormal electrical pathways in the heart. It is not an emergency intervention for pulseless VT. Defibrillation is needed to address the immediate, life-threatening situation.

Choice D reason: Administration of atropine is not indicated for pulseless VT. Atropine is used to treat bradycardia by increasing heart rate, but it does not address the underlying cause of VT. Defibrillation is the correct immediate intervention for pulseless VT.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings and validates their experience. It opens the door for the client to express their emotions and share their thoughts. This empathetic approach helps build trust and provides emotional support.

Choice B reason: Telling the client that it takes time to get over the loss of a loved one is a generalized statement that may not provide the support the client needs. It can come across as dismissive and may not encourage further conversation.

Choice C reason: Suggesting that the client try something to take their mind off their troubles can seem dismissive of their grief. It does not address the client's emotional needs or encourage them to talk about their feelings.

Choice D reason: While this response shows some understanding, it does not fully acknowledge the uniqueness of the client's situation. It is important to validate the client's feelings and encourage them to express their emotions.

A. The nurse waits 5 minutes between administering prescribed eye drops. B. The nurse leaves the eye shield in place while the client sleeps. C. The nurse is instructing the client not to drive at night. D. The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.

Correct Answer is D

Explanation

Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.

Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.

Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.

Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is found unresponsive and pulseless in their room. An ECG confirms the client is in pulseless ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

Correct Answer is D

Explanation

The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

During an emergency code situation, a primary healthcare provider about to defibrillate a client diagnosed with ventricular fibrillation says in a loud voice, "CLEAR!" Which action should the nurse implement immediately?

The nurse is assessing a client's eyes and notes that when the client looks at a near object, the pupil constricts, but when the client looks at an object in the distance, the pupil dilates. The nurse should identify this finding as which condition?

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

A nurse in the med-surgical ICU is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

A female client undergoing chemotherapy for breast cancer is distressed about hair loss. The most effective intervention by the nurse would be to:

A client diagnosed with acute kidney injury has an elevated blood urea nitrogen (BUN) and is experiencing difficulty remembering information. Which interventions should the nurse implement when communicating with this client? (Select all that apply)

A client diagnosed with angina pectoris appears to be very anxious and states, "So I had a heart attack, right?" Which response should the nurse make to the client?