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","B","E"]
Explanation
A. The ability to ambulate safely to the bathroom is a key indicator that the client can manage daily activities independently after discharge.
B. Normal bowel sounds and a soft abdomen indicate that there are no complications related to digestion, which is important for discharge readiness.
C. While the blood pressure of 142/94 mm Hg is elevated, it is not an immediate contraindication to discharge but should be monitored.
D. A pain rating of 5 may be acceptable depending on the client’s baseline, but if pain is not well controlled, discharge may need to be reconsidered.
E. Tolerance of oral medications is essential to ensure the client can continue managing pain at home without complications.
Correct Answer is A
Explanation
A. Identifying support systems is the first step in addressing the client’s emotional distress and providing the appropriate resources, such as therapy or support groups, for recovery.
B. Exploring feelings of hope is important, but first, it’s essential to establish a support system that can provide the client with the care they need.
C. Inquiring about plans for further education may not be appropriate at this moment, as the client’s emotional needs should take priority.
D. Explaining the ELISA test would be irrelevant since the client has already been diagnosed as HIV positive.
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