The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?

Correct Answer: C

Rationale: Assessing pulse confirms VF before proceeding with defibrillation or CPR.

Correct Answer: C

Rationale: Assessing the patient's readiness and strength before assisting them to stand prevents falls and injuries by ensuring they're physically capable of the transition. This involves checking their stability, pain level, and muscle strength, tailoring assistance accordingly. Telling them to stand alone risks harm if they're weak or dizzy. Pulling them abruptly ignores their condition and could cause strain or falls. Starting ambulation exercises immediately skips this critical safety step. Nurses prioritize patient safety assessment identifies risks like orthostatic hypotension or post-surgical weakness, ensuring a smooth, supported move that protects both patient and caregiver.

Correct Answer: B

Rationale: Providing verbal cues and guidance while walking beside a visually impaired patient ensures safe ambulation by compensating for their lack of sight with clear instructions and physical proximity. Walking unassisted risks falls or collisions, undermining safety over independence. Ignoring the impairment doesn't build resilience it neglects care duty and invites harm. Confinement sacrifices mobility and quality of life for false safety. Nurses use this supportive approach describing obstacles, offering an arm if needed to balance autonomy with protection, fostering confidence and preventing injuries in a tailored, compassionate way.

Correct Answer: C

Rationale: Securing a restraint to the bed's side rails ensures it holds the patient safely without slipping, preventing injury or escape while allowing some movement. Loose restraints defeat the purpose, risking falls or harm. Applying to the strong arm alone ignores full safety needs restraints typically involve both limbs or a vest. Using them as punishment is unethical; they're for protection, not discipline. Nurses follow this technique to balance safety and ethics, monitoring frequently to minimize use and maintain dignity, per legal and care standards.

Correct Answer: C

Rationale: Demonstrating the technique and providing positive reinforcement encourages effective incentive spirometry use by showing proper deep-breathing methods and motivating the patient with praise, improving lung expansion post-surgery. Rapid breathing defeats the goal slow, deep breaths are key. Shallow breaths reduce efficacy, risking atelectasis. Using it for the patient undermines their active role it's a self-exercise tool. Nurses model the process, set goals (e.g., volume markers), and cheer progress, enhancing compliance and respiratory health through empowerment and support.