A client with a permanent pacemaker has no pulse or spontaneous respirations and the monitor is displaying a ventricular fibrillation rhythm. Resuscitation is in progress and the nurse is preparing to defibrillate the client with 200 joules of unsynchronized defibrillation. Which intervention is most important for the nurse to implement?
Obtain 12-lead electrocardiogram to evaluate return of pacemaker's sensing, firing, and capture.
Ensure permanent pacemaker interrogated if return of spontaneous circulation is achieved.
Place self-adhesive defibrillator pads at least 1 inch away from permanent pacemaker site.
Apply a doughnut magnet over the pacemaker if pacer-mediated tachycardia develops.
The Correct Answer is C
A. Obtaining a 12-lead ECG is done after return of spontaneous circulation (ROSC), not during defibrillation.
B. Interrogating the pacemaker is important but is not the immediate priority during resuscitation.
C. Defibrillator pads should be placed at least 1 inch away from the pacemaker to prevent damage to the device and ensure effective defibrillation.
D. A doughnut magnet is used to deactivate pacemaker functions in cases like pacemaker-mediated tachycardia but is not relevant in ventricular fibrillation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Return demonstration is the most effective way to evaluate learning for a psychomotor skill like insulin injection. Observing the adolescent perform the procedure ensures he can correctly and safely self-administer insulin, which directly evaluates the effectiveness of teaching.
B: Reviewing glycosylated hemoglobin levels 3 months later will not assess the immediate effectiveness of the teaching or the adolescent’s ability to perform insulin injections.
C: Listing steps assesses cognitive understanding, but does not verify the psychomotor skill, which is critical.
D: Asking about comfort level is important for emotional support but does not directly assess the technical competency required for insulin administration.
Correct Answer is A
Explanation
A. Establish a structured routine for the client to follow. Establishing a consistent routine is essential to help clients with depression manage their symptoms and create a sense of structure and control. It can also help them feel more motivated to engage in activities.
B. Arrange a meeting with the family to discuss the client's situation. While family involvement is important, it is not the first priority. Immediate care interventions are needed to address the client’s current needs.
C. Assess the client's ability to communicate with the other staff members. While communication is important, the priority is to address the client’s physical and emotional needs by establishing a routine.
D. Administer the client's antidepressant medication as prescribed. Medication management is crucial, but the first step is to engage the client in a structured routine to help them begin functioning.
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