Exhibits

A nurse is assisting with the care of a client in the emergency department. The client is alert and oriented x3. Wheezing is noted on exhalation with a prolonged breathing cycle. The cough is nonproductive. Use of accessory muscles is noted while breathing. The oral mucosa and lips are cyanotic. Nasal flaring is noted. The client experiences difficulty talking.

The nurse is assisting in planning care. Complete the diagram by dragging from the choices below to specify:

1. What condition the client is most likely experiencing.
2. Two actions the nurse should take to address that condition.
3. Two parameters the nurse should monitor to assess the client’s progress.

Choice A rationale

Storing extra blankets in a box on the steps is not a safe practice for a client who has just returned home after a total hip arthroplasty. This could increase the risk of falls, which is a major concern after hip surgery.

Choice B rationale

Keeping pot handles turned towards the edge of the stove is not a safe practice. It increases the risk of spills and burns. Pot handles should always be turned towards the back of the stove to prevent accidents.

Choice C rationale

Placing electrical cords against the wall is a safe practice. It reduces the risk of tripping over the cords, which is especially important for a client who is recovering from a total hip arthroplasty.

Choice D rationale

Placing a throw rug next to the bathtub is not a safe practice. Throw rugs can easily slip and cause falls. A non-slip mat should be used instead.

Choice A rationale

Starting chest compressions is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While chest compressions are a part of cardiopulmonary resuscitation (CPR), they are not the initial response to ventricular tachycardia.

Choice B rationale

Immediate defibrillation is the priority action when a client’s cardiac monitor shows ventricular tachycardia. Ventricular tachycardia is a life-threatening condition where the heart

beats too fast to effectively pump blood to the body. Defibrillation delivers an electrical shock to the heart, which aims to restore a normal heart rhythm.

Choice C rationale

Providing pulmonary ventilation is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While ventilation is important, it is not the immediate priority in this situation.

Choice D rationale

Checking for a palpable pulse is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While it is important to assess the client’s pulse, the priority is to restore a normal heart rhythm through defibrillation.