A client in the CCU goes into sudden ventricular fibrillation. The priority action by the nurse would be to immediately administer
a. a lidocaine bolus.
b. atropine.
c. cardiopulmonary resuscitation (CPR).
d. intravenous (IV) magnesium.
C
When ventricular fibrillation appears, the nurse must immediately initiate CPR until the defibril-lator is engaged, and should defibrillate up to three times if needed. The only true effective treatment for ventricular fibrillation is defibrillation, which should occur as soon as possible.
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A child with Down's syndrome has been admitted to the hospital with a respiratory condition and is producing thick, tenacious mucus. Which nursing action is the priority?
A. Ensuring a patent airway B. Involving child-life therapy C. Preventing nosocomial infection D. Relieving stress at hospitalization
The therapeutic communication technique of suggesting is appropriate to use when it:
a. meets the patient's unmet dependency needs. b. shifts responsibility from the patient to the health care professional. c. is used during the working stage to present alternative coping strategies. d. is used early in the nurse-patient relationship to provide sound, everyday advice.
A patient who has breast cancer has been taking toremifene for 2 weeks. She tells her primary care NP that she thinks her tumor has grown larger. The NP should:
a. schedule her for a breast ultrasound. b. reassure her that this is common and will subside. c. tell her she may need an increased dose of this medication. d. contact her oncologist to discuss adding another medication.
A nurse is assessing a patient who complains of "awful" abdominal pain and rates it as a 9 on a scale of 0 to 10. Which of the following physiologic signs may accompany acute pain? Select all that apply
a. Tachycardia b. Irritability c. Increased blood pressure d. Depression e. Insomnia f. Sweating