After two minutes of cardiopulmonary resuscitation, the client's electrocardiogram (ECG) displays third degree heart block with no palpable pulse. Which intervention should the nurse implement?

Apply external pacing pads.

Obtain blood pressure reading.

Insert second peripheral IV.

Prepare epinephrine 1 mg IV.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Apply external pacing pads: Transcutaneous pacing is appropriate for symptomatic bradycardia with a pulse, not for pulseless electrical activity (PEA). In this case, the client has no pulse, so pacing will not generate effective cardiac output and should not be the first intervention.

B. Obtain blood pressure reading: During cardiac arrest, the client has no palpable pulse or measurable blood pressure. Attempting to obtain a blood pressure reading wastes valuable time that should be spent on life-saving interventions such as medication administration and high-quality CPR.

C. Insert second peripheral IV: While establishing additional IV access can be useful for administering fluids or medications, it is not the immediate priority during a pulseless event. The focus should remain on pharmacologic support and maintaining perfusion through CPR.

D. Prepare epinephrine 1 mg IV: Epinephrine is the first-line medication for PEA and asystole because it enhances myocardial contractility and increases coronary and cerebral perfusion during CPR. It should be administered as soon as possible, followed by continued chest compressions and rhythm reassessment every 2 minutes.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Skeletal traction misalignment: While misalignment can cause discomfort and complications in spinal cord injury clients, it is not the most common or immediate trigger of autonomic dysreflexia. Assessment of alignment is secondary to more urgent causes of sympathetic overactivity.

B. Profuse forehead diaphoresis: Sweating is a symptom of autonomic dysreflexia but is a manifestation rather than a precipitating factor. Identifying the cause of the dysreflexia takes priority over treating symptoms alone.

C. An acutely distended bladder: Bladder distension is the most common precipitating factor for autonomic dysreflexia in clients with lesions at T6 or above. Immediate assessment and relief of urinary retention are critical to prevent severe hypertension, stroke, or other life-threatening complications.

D. A severe pounding headache: Headache is a classic symptom of autonomic dysreflexia, reflecting elevated blood pressure. While important to recognize, it indicates the presence of the condition rather than identifying the cause that must be addressed first.

A. Orient the client to her surroundings. B. Allow husband to stay at bedside. C. Implement seizure precautions. D. Assess for drainage from ears or nose.

Correct Answer is D

Explanation

Rationale:
A. Orient the client to her surroundings: While orientation is helpful for confusion, the client’s restlessness and confusion could indicate increasing intracranial pressure or cerebral bleeding, which require immediate physical assessment rather than reassurance.

B. Allow husband to stay at bedside: Allowing the husband to remain can provide emotional support, but this is not the priority when assessing for potentially life-threatening neurological changes. Emotional comfort is secondary to detecting and managing complications of head trauma.

C. Implement seizure precautions: Seizure precautions are appropriate for clients with head injuries but should follow a focused neurological assessment. Detecting cerebrospinal fluid (CSF) leakage or signs of skull fracture takes precedence because it indicates a severe brain injury requiring urgent intervention.

D. Assess for drainage from ears or nose: Clear or bloody drainage may indicate CSF leakage due to a basilar skull fracture. Identifying this finding early is critical to prevent infection, monitor for increased intracranial pressure, and guide emergent management, making this the most important immediate nursing action.

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

After two minutes of cardiopulmonary resuscitation, the client's electrocardiogram (ECG) displays third degree heart block with no palpable pulse. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a C-7 spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

Patient Data Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.

A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

Patient Data Exhibits The rapid response team (RRT) is on its way to the bedside. Which 4 actions should the nurse perform immediately?

While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately?

Four days ago, a chest tube was inserted into the second intercostal space (ICS) of a client with a pneumothorax. Today the nurse notes that there is no fluctuation in the water seal chamber of the chest tube drainage system. Which intervention should the nurse implement next?

The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?

A young man playing football in the park sustains a hard hit and is lying motionless on the ground, while his friends are trying to help him. Which action by his friends warrants immediate intervention by the nurse who was watching from the sidelines?