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 B
Explanation
Choice A rationale
Idiopathic vasospasm, or spontaneous constriction of the blood vessels, can cause myocardial ischemia. However, this is a relatively rare cause compared to atherosclerosis.
Choice B rationale
Atherosclerosis, a condition characterized by the buildup of fatty plaques in the arteries, is the most common cause of myocardial ischemia. These plaques can restrict blood flow to the heart muscle, leading to ischemia.
Choice C rationale
Venous emboli, or blood clots that form in the veins, typically do not cause myocardial ischemia. These clots are more likely to cause problems in the lungs (pulmonary embolism) if they travel through the bloodstream.
Choice D rationale
Arterial emboli from a heart valve can cause myocardial ischemia, but this is less common than atherosclerosis. These emboli, or blood clots, can block blood flow to the heart muscle if they travel through the bloodstream.
Correct Answer is D
Explanation
Choice A rationale
Serum hemoglobin of 14.7 g/dL is within the normal range for adults, which is typically 12.0 to
16.0 g/dL for women and 13.5 to 17.5 g/dL for men. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. While it’s important to monitor hemoglobin levels, a value of 14.7 g/dL does not raise immediate concerns related to hypertension.
Choice B rationale
A blood glucose level of 96 mg/dL is considered normal. The normal range for fasting blood glucose is between 70 and 100 mg/dL1. Blood glucose levels are important to monitor, especially in patients with diabetes, but a value of 96 mg/dL is not immediately concerning in the context of hypertension.
Choice C rationale
A serum potassium level of 4.5 mEq/L is within the normal range, which is typically 3.6 to 5.2 mEq/L1. Potassium is an essential electrolyte that helps regulate heart and muscle contractions and maintain fluid balance in the body. While it’s important to monitor potassium levels, a value of 4.5 mEq/L does not raise immediate concerns related to hypertension.
Choice D rationale
A serum creatinine level of 2.8 mg/dL is high. Creatinine is a waste product that’s produced by your muscles and filtered out of your blood by your kidneys. High levels of creatinine can indicate that the kidneys aren’t working properly, which can be a complication of hypertension. Therefore, this result is the most important to communicate to the healthcare provider.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.