An adult who fell 20 feet (6 meters) from a tree is admitted to the intermediate intensive care unit with a fractured femur. When the cardiac monitor alarms, the nurse finds the client has no palpable carotid pulse and no spontaneous respiration, however, the cardiac monitor displays a sinus rhythm. Which intervention should the nurse implement?

View the rhythm in another chest lead.

Begin chest compressions at a rate of 120 times a minute.

Auscultate all chest fields for muffled lung sounds.

Observe for swelling at the fracture site.

Answer and Explanation

The Correct Answer is B

A. View the rhythm in another chest lead. While verifying the rhythm in another lead may help confirm the accuracy of the monitor, it does not address the immediate absence of a pulse and respirations. The client is in pulseless electrical activity (PEA), which requires immediate intervention rather than rhythm verification.
B. Begin chest compressions at a rate of 120 times a minute. The client has no palpable carotid pulse and no spontaneous respirations despite a sinus rhythm on the monitor, indicating pulseless electrical activity (PEA). PEA is a form of cardiac arrest where the heart shows electrical activity but fails to generate effective circulation. Immediate high-quality chest compressions are essential to maintain perfusion while addressing the underlying cause, such as hypovolemia or tension pneumothorax.
C. Auscultate all chest fields for muffled lung sounds. While assessing for muffled lung sounds may help detect conditions such as tension pneumothorax or hemothorax, it should not delay the initiation of CPR. Once compressions are started, the underlying cause of PEA can be investigated.
D. Observe for swelling at the fracture site. Swelling at the fracture site may indicate bleeding or compartment syndrome, but assessing the fracture should not take priority over initiating CPR. If hemorrhage is suspected as a cause of PEA, rapid fluid resuscitation should be initiated after starting chest compressions.

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 C

Explanation

A. Suture removal kit. A suture removal kit is used when the chest tube is ready for removal, but it is not necessary to keep at the bedside during routine chest tube management. The priority is ensuring emergency supplies are available if the tube becomes dislodged.
B. Suction catheter. A suction catheter is used to remove secretions from the airway but is not essential for managing a chest tube. Chest drainage systems function independently to remove air or fluid, and routine suctioning is not required for chest tube management.
C. Sterile gauze dressing. If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
D. Sterile piston syringe. A sterile piston syringe is used for irrigating wounds or suctioning secretions, but it is not necessary for chest tube management. The closed drainage system should never be manually flushed unless specifically ordered by a healthcare provider.

A. Temperature. B. Heart sounds. C. Urinary output. D. Pupil response.

Correct Answer is C

Explanation

A. Temperature. While temperature monitoring is important in septic shock to assess infection control, it is not an indicator of dopamine's effectiveness. Dopamine primarily affects renal perfusion and blood pressure, not body temperature regulation.
B. Heart sounds. Dopamine is a vasopressor and inotropic agent, but it does not directly impact heart sounds. While it can increase myocardial contractility, assessing blood pressure and perfusion parameters is more relevant in evaluating its therapeutic effects.
C. Urinary output. Low-dose dopamine (1-5 mcg/kg/min) primarily acts as a dopaminergic agonist, increasing renal blood flow and urine output by dilating renal arteries. In septic shock, maintaining adequate kidney perfusion is critical to prevent acute kidney injury (AKI). A therapeutic response to dopamine would be seen as improved urinary output (≥ 30 mL/hr), indicating effective renal perfusion.
D. Pupil response. Dopamine does not directly affect pupil size or reactivity. Pupil assessment is more relevant in neurological evaluations, not in monitoring the effects of dopamine in septic shock.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

Correct Answer is C

Explanation

The nurse is administering low dose dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to the dopamine?

Correct Answer is C

Explanation

A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?

After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?

Based on this rhythm strip, which interpretation should the nurse make?