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 D
Explanation
A. Altered nutrition is a concern but is not the immediate priority.
B. Activity intolerance is expected but does not pose an immediate threat.
C. Fluid volume excess should be monitored, but ineffective airway clearance poses a more immediate risk.
D. Ineffective airway clearance is the highest priority because a flank incision can cause significant pain, leading to shallow breathing and increased risk for atelectasis or pneumonia.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"D"}
Explanation
Appendicitis is the most likely diagnosis, given the right lower quadrant (RLQ) pain, fever, nausea, vomiting, and CT findings of a dilated appendix with fat stranding. CT scan results confirming appendix dilation and fat stranding indicate inflammation, which is characteristic of appendicitis. WBC count is often elevated in appendicitis due to the inflammatory response and potential infection. Gastroenteritis is unlikely since there is no history of diarrhea or recent illness, and pneumonia is not relevant given the primary abdominal symptoms.
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