🔷 In adult CPR, the priority is to begin high-quality chest compressions immediately once cardiac arrest is identified.

🔷 Current CPR practice emphasizes circulation first, because maintaining blood flow to the brain and heart is critical.

🔷 Effective compressions should be delivered at a rate of 100 to 120 per minute with adequate depth and full chest recoil.

🔷 Delays in compressions reduce survival chances, so compressions should start promptly.

🔷 Therefore, the nurse should first provide chest compressions at a rate of 100/min.

Complete two cycles of CPR before using the external defibrillator (AED).

🔷 The AED should be applied as soon as it is available, not delayed for two full cycles if it can be used sooner.

🔷 Early defibrillation is important in shockable rhythms.

After a set of 50 compressions, give the client 2 rescue breaths.

🔷 Adult CPR is not performed in sets of 50 compressions.

🔷 The standard compression-to-ventilation ratio is 30 compressions to 2 breaths when no advanced airway is in place.

Check for a brachial pulse before administering CPR.

🔷 A brachial pulse is checked in infants, not adults.

🔷 For adults, the pulse assessment is typically carotid, and if no pulse is present, compressions begin immediately.

💠 Sequential compression devices (SCDs) help prevent deep vein thrombosis by promoting venous return from the legs while the client is inactive in bed.

💠 Postoperative clients are at increased risk for DVT because of immobility, venous stasis, and inflammatory changes after surgery.

💠 SCDs provide repeated intermittent compression that reduces blood pooling in the lower extremities.

💠 They are a standard and effective DVT prevention measure when used consistently.

💠 Therefore, applying continuous SCDs while in bed is the best intervention.

Ambulate to the bathroom once daily for personal care

💠 Walking only once daily is not enough to provide strong DVT prevention for a postoperative client.

💠 Early and more frequent ambulation is beneficial, but this option is too limited.

Elevate bilateral lower extremities while resting

💠 Elevation can reduce swelling, but it is not as effective as SCDs for preventing postoperative DVT.

💠 The best answer is the intervention specifically designed to reduce venous stasis.

Apply TED hose during nighttime hours.

💠 TED hose may help, but using them only at night is not the most effective prevention strategy.

💠 Continuous SCD use while in bed provides stronger DVT prevention in the immediate postoperative period.

🟢 In immune thrombocytopenic purpura (ITP), platelets are destroyed prematurely because the immune system targets them.

🟢 The spleen is the major site where these antibody-coated platelets are removed from circulation.

🟢 Removing the spleen can reduce platelet destruction and improve the platelet count in clients whose ITP is severe or persistent.

🟢 This is why splenectomy may be used when medical therapy is not sufficient.

🟢 Therefore, the primary reason for splenectomy is that the spleen is the primary site of platelet destruction.

The spleen is at risk for infection due to the critical loss of WBCs.

🟢 ITP is a platelet disorder, not primarily a white blood cell disorder.

🟢 The reason for splenectomy is not critical loss of WBCs.

The spleen becomes engorged and ischemic during an ITP crisis

🟢 Splenectomy in ITP is not done because the spleen becomes ischemic during a crisis.

🟢 The procedure is done to reduce immune-mediated platelet destruction.

The spleen causes an overabundance of immature platelets.

🟢 The spleen does not cause excess immature platelets in ITP.

🟢 The central problem is platelet destruction, not overproduction of immature platelets.

🔷 Polycythemia vera is a myeloproliferative disorder in which the bone marrow produces too many red blood cells, and often other blood cells as well.

🔷 Because the excess RBC production is coming from the marrow itself, the erythropoietin level is usually low due to negative feedback.

🔷 A high hematocrit and high RBC count are classic laboratory findings because the blood becomes abnormally concentrated with red cells.

🔷 This combination increases blood viscosity and raises the risk for thrombosis, headache, and hypertension.

🔷 Therefore, the finding most consistent with polycythemia vera is high hematocrit, high RBC count, and low erythropoietin levels.

Elevated erythropoietin levels with a normal red blood cell count

🔷 Elevated erythropoietin with a normal RBC count does not fit polycythemia vera.

🔷 Polycythemia vera is characterized by increased RBC production and usually suppressed erythropoietin levels.

Normal hematocrit with a high white blood cell count

🔷 A normal hematocrit does not support the diagnosis of polycythemia vera because the disorder typically causes an elevated hematocrit.

🔷 Although white blood cells may also rise, the hallmark feature is excess red blood cells.

Low hematocrit and low red blood cell count

🔷 Low hematocrit and low RBC count are findings more consistent with anemia, not polycythemia.

🔷 Polycythemia vera is the opposite pattern, with excess circulating red cells.

Avoid magnetic fields and high voltage

💠 Clients with a permanent pacemaker should avoid strong magnetic fields and high-voltage environments because these can interfere with pacemaker function.

💠 Strong electromagnetic interference may temporarily disrupt sensing or pacing activity.

💠 Discharge teaching should include avoiding industrial magnets, certain heavy electrical equipment, and other strong field sources.

💠 This teaching helps protect the device from malfunction.

💠 Therefore, avoiding magnetic fields and high voltage is an appropriate discharge instruction.

Report dizziness, irregular heartbeats and palpitations

💠 Symptoms such as dizziness, palpitations, syncope, or irregular heartbeats may indicate pacemaker malfunction or failure to capture properly.

💠 These symptoms require prompt evaluation because they may mean the device is not maintaining the needed heart rhythm.

💠 Early reporting can prevent worsening instability or complications.

💠 The client should understand that these are not normal findings to ignore after discharge.

💠 Therefore, this is an essential discharge instruction.

Wear a medical alert identification

💠 A medical alert ID is important because it lets emergency personnel know the client has a pacemaker.

💠 This can guide decisions about diagnostic procedures, emergency treatment, and use of electrical equipment.

💠 It also helps ensure safer care if the client becomes unable to communicate.

💠 Wearing identification is a standard safety recommendation after pacemaker placement.

💠 Therefore, the client should wear a medical alert identification.

Return to normal activities, including sports right away

💠 The client should not return to full activity or sports immediately after pacemaker insertion.

💠 Activity is usually restricted for a period to allow the leads to stabilize and the incision to heal.

Avoid microwave appliances in use

💠 Modern pacemakers are generally safe around household microwave appliances in normal use.

💠 This is an outdated restriction and is not standard discharge teaching.

Avoid lifting anything more that 1 pound

💠 Lifting restrictions are needed initially, but 1 pound is unrealistically strict and not the usual teaching.

💠 The client is generally instructed to avoid lifting the affected arm above the shoulder and avoid heavier lifting for a prescribed period.

🔶 ST-segment elevation with chest pain strongly suggests an acute myocardial infarction, which is a time-sensitive emergency.

🔶 Rapid intervention is essential because myocardial tissue is being injured and delays can worsen damage.

🔶 The nurse must immediately escalate care so that urgent treatment such as reperfusion therapy can be started.

🔶 Continuing routine assessment or simply observing the ECG would waste critical time.

🔶 Therefore, the priority action is to alert the supervising RN and the physician immediately.

Auscultate chest sounds and continue physical assessment.

🔶 Further assessment may be needed, but it is not the priority when the client already has chest pain and ST elevation.

🔶 Immediate escalation of care takes precedence.

Continue to monitor the ECG to determine if ST segment depression continues.

🔶 The finding is ST elevation, not depression, and this should not simply be watched without action.

🔶 The nurse must respond urgently to suspected myocardial infarction.

Review the electrocardiogram (ECG) recordings in the patient's chart.

🔶 Reviewing old ECGs may be useful later, but it is not the first priority in an acute event.

🔶 The immediate need is rapid notification and treatment.

🔷 Atrial flutter is the best answer because the ECG strip shows regular, sawtooth-shaped flutter waves between the QRS complexes, which are a classic hallmark of this rhythm.

🔷 The rhythm appears organized and regular, which helps distinguish it from atrial fibrillation, where the rhythm is typically irregularly irregular.

🔷 In atrial flutter, the atria usually depolarize very rapidly, often at a rate of 250 to 350 beats/min, producing the characteristic flutter appearance on the strip.

🔷 The QRS complexes here are relatively uniform and narrow, which supports a supraventricular rhythm such as atrial flutter rather than a ventricular-origin rhythm.

🔷 Recognizing atrial flutter is important because it can reduce effective atrial contraction and increase the client’s risk for thromboembolic complications if not properly managed.

STEMI

🔷 STEMI is identified primarily by ST-segment elevation in contiguous leads, not by sawtooth atrial activity.

🔷 This strip is showing an arrhythmia pattern, not the classic ischemic ST-segment changes expected with STEMI.

Atrial Fibrillation

🔷 Atrial fibrillation usually has an irregularly irregular ventricular rhythm and does not produce the distinct, repetitive sawtooth flutter waves seen here.

🔷 Because this strip looks more regular and patterned, atrial fibrillation is less likely.

Tachycardia

🔷 Tachycardia is a general term meaning a fast heart rate, but it does not specifically identify the rhythm shown on the strip.

🔷 This question asks for the specific cardiac rhythm, and the visible flutter waves make atrial flutter the more accurate diagnosis.

🟣 A patient with atrial fibrillation reporting dyspnea requires assessment first because dyspnea is a sign of decreased cardiac output or worsening cardiopulmonary compromise.

🟣 Atrial fibrillation can reduce ventricular filling and impair effective circulation, especially when symptoms are present.

🟣 The priority is not just the rhythm itself, but the fact that the client is symptomatic, which may indicate poor perfusion, heart failure, or embolic complications.

🟣 In prioritization, the nurse should assess the client with the most urgent signs of instability, and shortness of breath is a concerning finding.

🟣 This client may need immediate assessment of oxygenation, hemodynamic status, and response to the dysrhythmia.

A patient with premature atrial contractions who is asymptomatic.

🟣 Premature atrial contractions are often benign, especially when the patient has no symptoms.

🟣 This finding does not suggest immediate instability compared with a symptomatic client with atrial fibrillation.

A patient with sinus tachycardia with a heart rate of 108 beats/minute.

🟣 A heart rate of 108 beats/minute is only mildly elevated and may occur with pain, anxiety, fever, or activity.

🟣 Without symptoms or signs of instability, this patient is not the highest priority.

A patient with sinus bradycardia, a heart rate of 53 beats/min, and blood pressure of 100/60.

🟣 Sinus bradycardia at 53 beats/min can be tolerated if the patient remains stable and perfusing adequately.

🟣 A blood pressure of 100/60 is lower than average but does not alone indicate the same urgency as dyspnea with atrial fibrillation.