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During hourly rounding the nurse enters a room where the client is unresponsive without pulse. What is the nurse's priority action?
- A. Begin ventilation at 1 breath every 6-8 seconds
- B. Start chest compressions at a rate of 100-120 compressions per minute
- C. Wait for the emergency response team for direction
- D. Call the family
Correct Answer: B
Rationale: No pulse, no response cardiac arrest kicks in chest compressions, 100-120/min, pumping life per ACLS, trumping breaths first in lone-rescuer mode. Waiting or calling delays; ventilation follows. Nurses hammer compressions, buying brain time, a priority slam in this code blue crash.
You may also like to solve these questions
In the ACC/AHA 2017 Guideline for Hypertension, what is the cut off for hypertension diagnosis?
- A. 120/70 mmHg
- B. 130/80 mmHg
- C. 135/85 mmHg
- D. 140/90 mmHg
Correct Answer: B
Rationale: ACC/AHA 2017 130/80 tags hypertension, not old 140/90 or looser. Nurses gauge this chronic pressure shift.
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
- A. Generalized muscle aches
- B. Crackles heard at the lung bases
- C. Complaints of nausea and anorexia
- D. Oral temperature of 100.6°F (38.1°C)
Correct Answer: B
Rationale: IL-2 can spark capillary leak crackles at lung bases signal pulmonary edema, an emergency needing fast action over aches , nausea , or low fever , all common. Nurses in oncology flag this fluid in lungs kills quick, demanding stat calls.
The client is admitted for heart failure and has edema, neck vein distension, and ascites. What is the most accurate way to monitor fluid gain or loss in this client?
- A. Auscultate the lungs for crackles or wheezing
- B. Weigh the client daily at the same time with the same scale
- C. Check for pitting edema in the dependent body parts
- D. Assess skin turgor and the condition of mucus membranes
Correct Answer: B
Rationale: Heart failure's fluid dance edema, JVD, ascites needs precise tracking. Daily weights, same time, same scale, catch 1 kg shifts (1 L fluid), the gold standard for gain or loss, outpacing lung sounds' subjectivity. Edema checks or turgor gauge trends, less exact. Nurses weigh in, ensuring diuretic tweaks hit the mark, a reliable ruler in this swollen saga.
A client diagnosed with stable angina is complaining of substernal chest pain, rating the pain 5 out of 10. What would be the priority action by the nurse?
- A. Administer the client's prescribed beta-blocker
- B. Administer nitroglycerin intravenously immediately
- C. Administer morphine
- D. Administer 325 mg of chewable aspirin immediately
Correct Answer: D
Rationale: Stable angina's oxygen pinch 5/10 pain bows to aspirin's antiplatelet punch, cutting clot risk fast, a priority over beta-blockers' slow rate drop. IV nitroglycerin's for MI, morphine's overkill, aspirin's chewed for quick absorption. Nurses hit this, easing ischemia, a front-line move in this chest squeeze.
In which of these do you see clue cells?
- A. trichomonas vaginalis
- B. bacterial vaginosis
- C. candida
- D. HSV 2
Correct Answer: B
Rationale: Clue cells BV's fishy flag, not trich's swim, candida's yeast, HSV's sores, or syphilis' chancre. Nurses scope this chronic hint.