Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?
Initiate cardiopulmonary resuscitation (CPR).
Establish intravenous (IV) access.
Carry out immediate defibrillation.
Check the client’s latest electrolyte levels.
The Correct Answer is C
The correct answer is choice c. Carry out immediate defibrillation.
Choice A rationale:
Initiating cardiopulmonary resuscitation (CPR) is essential for a client who is unresponsive and without a pulse. However, in the presence of ventricular fibrillation, immediate defibrillation is the priority to restore a viable heart rhythm.
Choice B rationale:
Establishing intravenous (IV) access is important for administering medications during resuscitation. However, it is not the immediate priority when defibrillation is indicated.
Choice C rationale:
Immediate defibrillation is the priority action for a client with ventricular fibrillation who is unresponsive and without a pulse. Defibrillation can quickly restore a normal heart rhythm, which is critical in saving the client’s life.
Choice D rationale:
Checking the client’s latest electrolyte levels can provide valuable information for ongoing treatment but is not the immediate priority in an emergency situation where defibrillation is indicated. Immediate action to restore the heart rhythm is more critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Secondary hypertension is high blood pressure that is caused by another medical condition or medication. It is not the most common type of hypertension.
Choice B rationale
Congenital hypertension is not a recognized type of hypertension. Hypertension can be associated with some congenital conditions, but it is not a type of hypertension itself.
Choice C rationale
Acquired hypertension is not a recognized type of hypertension. While lifestyle factors can contribute to the development of hypertension, the term “acquired hypertension” is not typically used.
Choice D rationale
Primary hypertension, also known as essential hypertension, is the most common type of hypertension. It is high blood pressure that does not have a known secondary cause.
Correct Answer is A
Explanation
Choice A rationale
Keeping hands warm and wearing gloves when handling cold objects is one of the most effective ways to manage Raynaud’s disease. Cold temperatures can trigger Raynaud’s attacks, which can cause the fingers to turn white, then blue, and feel cold and numb.
Choice B rationale
While avoiding standing for prolonged periods can be beneficial for certain conditions, it is not specifically related to managing Raynaud’s disease.
Choice C rationale
Regular exercise can help improve circulation, which can be beneficial for people with Raynaud’s disease. However, it’s not as crucial as keeping the hands warm.
Choice D rationale
Regularly returning to the clinic for blood pressure checks is not specifically related to managing Raynaud’s disease. While it’s important for individuals with certain conditions, such as hypertension, to regularly monitor their blood pressure, it’s not a key aspect of managing Raynaud’s disease.
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