When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?
Observe for swelling at the fracture site.
Analyze the cardiac rhythm in another lead.
Obtain a 12-lead electrocardiogram.
Begin chest compressions at 100/minute.
The Correct Answer is D
The correct answer is choice D: Begin chest compressions at 100/minute.
Choice A rationale:
Observing for swelling at the fracture site is not immediately relevant in this emergency situation. The priority is to address the lack of pulse and respiration.
Choice B rationale:
Analyzing the cardiac rhythm in another lead is unnecessary when the patient has no pulse and is not breathing. Immediate life-saving measures are required.
Choice C rationale:
Obtaining a 12-lead electrocardiogram is not the priority in this scenario. The patient needs immediate resuscitation efforts.
Choice D rationale:
Beginning chest compressions at 100/minute is the correct intervention. The absence of a carotid pulse and spontaneous respirations indicates cardiac arrest, and chest compressions are essential to maintain circulation and oxygenation until further help arrives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- This is true; the diaphragm should be inserted before sexual activity. However, the main concern in this scenario is the need for refitting after childbirth.
B) Incorrect- This statement is not accurate. While the diaphragm is a form of contraception, it is not considered one of the most effective methods. Long-acting reversible contraceptives
(LARCs) like intrauterine devices (IUDs) and hormonal implants are among the most effective methods.
C) Incorrect- Vaseline lubricant can be used when inserting the diaphragm: Vaseline and other oil-based lubricants can weaken the latex or cause damage to the diaphragm. Water-based lubricants are recommended for use with diaphragms.
D) Correct- The diaphragm is a barrier contraceptive device that is inserted into the vagina before sexual intercourse to prevent pregnancy. However, its effectiveness can be compromised by changes in the anatomy of the vaginal canal, cervix, and pelvic structures, such as those that occur after childbirth. After vaginal childbirth, the pelvic structures may undergo changes, including stretching and possible loss of tone. These changes can affect the fit and position of the diaphragm, leading to decreased contraceptive efficacy. Therefore, it's important for women who have given birth to have their diaphragm refitted by a healthcare provider before resuming its use.
Correct Answer is A,B,C,D,E
Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
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.