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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Auscultation is generally used to assess bowel sounds or lung sounds, not urinary retention.

B. Measuring girth may be useful for assessing ascites or other fluid retention but is not specific to urinary retention.

C. Observing the appearance of urine is not directly useful for detecting retention. Retention is about the inability to void despite the urge, and urine may or may not be visibly affected.

D. Palpation above the pubic symphysis is the most effective way to assess for urinary retention because the bladder is located in this area. A distended bladder, which is a sign of retention, can often be palpated here.

A. Keep the room brightly lit while providing care. B. Monitor for change in speech. C. Report any change in level of consciousness. D. Minimize verbal interaction with the client. E. Avoid dropping side rails or abruptly closing the door.

Correct Answer is ["B","C","E"]

Explanation

A. Keeping the room brightly lit may contribute to confusion or agitation, especially in an acute stroke client.

B. Monitoring speech for changes is critical in stroke patients, as sudden changes can indicate worsening neurological status.

C. Changes in level of consciousness can indicate deterioration, and should be promptly reported to the nurse.

D. Minimizing verbal interaction may not be helpful as it could isolate the client. It's more important to provide clear and calm communication.

E. Avoiding sudden movements or sounds, such as dropping side rails or abruptly closing doors, can help reduce agitation and prevent injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

Exhibits The nurse reviews the findings in the history and physical. Drag from word choices to complete the sentence. The nurse recognizes that dropdown,dropdown, anddropdownare findings consistent with elder mistreatment.

A client who fell and broke a wrist is admitted for 24 hour observation after emergency orthopedic surgery. The healthcare provider prescribes discharge in the morning. Which finding(s) should the nurse use to evaluate the client's status for discharge from the hospital? Select all that apply.

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

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