Rationales A: why the priority beat the algorithm

Item 1 — Answer: 2

• Why 2 is right. The strip is monomorphic ventricular tachycardia, and everything that follows depends on whether it is perfusing. The pulse check decides between synchronized cardioversion and compressions with defibrillation. → BOOK 08 · P7
• Why 1 is wrong. A precordial thump is not a nursing action for an unwitnessed rhythm and delays the assessment. RECITED THE ALGORITHM
• Why 3 is wrong. Access matters, but it never precedes finding out whether the patient has a pulse. RIGHT ACTION, WRONG ORDER
• Why 4 is wrong. Observation is documentation of a delay in a rhythm that arrests. SKIPPED THE ASSESSMENT
• The rule: wide, fast, and regular sends your fingers to the neck before anything else.

Item 2 — Answer: 2

• Why 2 is right. Elevation in II, III, and aVF is inferior, which means right coronary and probable right ventricular involvement. That ventricle is preload dependent, and the nitrate has just removed the filling it was living on. Stop the drug, restore filling, notify. → BOOK 08 · P4
• Why 1 is wrong. Repeating the drug that caused the fall repeats the harm. TREATED THE NUMBER
• Why 3 is wrong. An opioid drops preload further in a patient who has none to spare. RECITED THE ALGORITHM
• Why 4 is wrong. Sitting the patient up reduces venous return, and fifteen minutes is not a plan. SKIPPED THE ASSESSMENT
• The rule: hypotension right after a dose that should have helped is the drug talking.

Item 3 — Answer: 1, 2, 4, 5

• Why 1 is right. Distended neck veins are systemic venous backup, which is the right heart. → BOOK 08 · P6
• Why 2 is right. Dependent edema shifts to the sacrum when the patient lies down, which is why you look there.
• Why 4 is right. Hepatic congestion produces enlargement and right upper quadrant tenderness.
• Why 5 is right. Ascites is the abdominal expression of the same backup, and girth is the way it is measured.
• Why 3 is wrong. Pink frothy sputum is acute pulmonary edema, which is left-sided. ANSWERED A DIFFERENT PATIENT
• Why 6 is wrong. Orthopnea is pulmonary congestion and belongs to the left column. ANSWERED A DIFFERENT PATIENT
• The rule: lungs are left, everything below the diaphragm is right.

Item 4 — Answer: 2, 1, 3, 4

• Why this order is right. Monitoring and vital signs are the assessment that tells you whether you have minutes or seconds. The twelve-lead follows immediately and must be read within ten minutes of arrival. Access comes next so treatment is possible. Aspirin is given after screening, because it is a medication with contraindications. → BOOK 08 · P9
• Why 1 is not first. The tracing is essential but it is not the first thing you do to a patient you have not yet assessed. RIGHT ACTION, WRONG ORDER
• Why 3 is not first. Access supports treatment that has not yet been chosen. RIGHT ACTION, WRONG ORDER
• Why 4 is not first. A medication never precedes the assessment that screens it. SKIPPED THE ASSESSMENT
• The rule: assess, then image the rhythm, then open a route, then treat.

Item 5 — Answer: 3

• Why 3 is right. A measured unilateral difference with warmth after immobility is deep vein thrombosis until imaging says otherwise. Keeping the limb still and reporting are the nursing actions. → BOOK 08 · P6
• Why 1 is wrong. Massage can dislodge a clot and cause pulmonary embolism. This is direct patient harm. RECITED THE ALGORITHM
• Why 2 is wrong. Walking a suspected clot before evaluation is the same harm with more steps. SKIPPED THE ASSESSMENT
• Why 4 is wrong. Heat and elevation may be ordered later; neither is the first action, and neither replaces notification. RIGHT ACTION, WRONG ORDER
• The rule: one leg bigger than the other means hands off and phone up.

Item 6 — Answer: 2

• Why 2 is right. The client is stable, so the priority is data: an apical-radial deficit quantifies how many beats are not perfusing, and onset time drives the clot and cardioversion decision. → BOOK 08 · P7
• Why 1 is wrong. Cardioversion is for instability, and this client has none. RECITED THE ALGORITHM
• Why 3 is wrong. Giving the drug before the assessment removes the baseline you need to evaluate it. SKIPPED THE ASSESSMENT
• Why 4 is wrong. Oxygen is not indicated at a normal saturation and lying flat helps nothing here. TREATED THE NUMBER
• The rule: stable means you have time to gather the two facts that change management.

Item 7 — Answer: 1, 2, 3, 4, 6

• Why 1 is right. A single shock with full recovery is reported, not ignored and not an emergency call.
• Why 2 is right. Repeated shocks or shocks with symptoms mean the underlying rhythm is not controlled. → BOOK 08 · P8
• Why 3 is right. Bystanders are not harmed, and saying so keeps families from stepping away during a collapse.
• Why 4 is right. The card explains the device and the screening alarm.
• Why 6 is right. Distance and opposite-side use prevent interference.
• Why 5 is wrong. Only devices labeled as conditional may be scanned, and only under a specific protocol. ANSWERED A DIFFERENT PATIENT
• The rule: one shock is a phone call, more than one is an ambulance.

Item 8 — Answer: 2

• Why 2 is right. Spikes are firing on time and producing nothing, so the stimulus is not capturing the ventricle, and the effective rate has fallen below the programmed rate. → BOOK 08 · P8
• Why 1 is wrong. Failure to sense puts spikes where they do not belong, at intervals unrelated to intrinsic beats. ANSWERED A DIFFERENT PATIENT
• Why 3 is wrong. Normal pacing answers every spike with a complex and every complex with a pulse. SKIPPED THE ASSESSMENT
• Why 4 is wrong. Inhibition means the device withholds a spike; here the spikes are present. TREATED THE NUMBER
• The rule: spike with nothing after it is capture; spike where it does not belong is sensing.

The algorithm note. Several distractors in this set are correct resuscitation steps offered at the wrong moment, which is precisely how the exam separates a nurse who assesses from a candidate who memorizes.

Margin notecount your tags, the pattern is the study plan.

Priority frameworks live at → BOOK 03 · P5. Values live at → BOOK 07 · P4.

Takeawaythe distractor you chose names the habit you need to break.