Following two defibrillation shocks, the client's electrocardiogram (ECG) continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next?

Resume CPR immediately.

Obtain an arterial blood gas sample.

Perform the third defibrillation shock.

Administer an IV bolus of epinephrine.

Answer and Explanation

The Correct Answer is C

Choice A: CPR is important but should be performed in conjunction with defibrillation. Since two defibrillation shocks have already been administered, the next step should be another shock.

Choice B : Obtaining an arterial blood gas sample is not the immediate priority when the client is in ventricular fibrillation. Defibrillation should be continued.

Choice C: Performing the third defibrillation shock is the next appropriate step in the advanced cardiac life support (ACLS) algorithm for ventricular fibrillation.

Choice D: Administering an IV bolus of epinephrine may be part of the ACLS protocol, but it is typically administered after defibrillation attempts.

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Correct Answer is A

Explanation

Choice A: Performing a fundal massage is the first priority in this situation to assess and manage uterine tone and prevent postpartum hemorrhage.

Choice B: Drawing blood for hemoglobin and hematocrit can be important but is not the immediate priority when the client has just delivered outside the hospital.

Choice C: Obtaining a complete obstetrical history is important but can be done after addressing the immediate postpartum concerns.

Choice D: Inspecting the perineum for lacerations is also important but should be done after addressing uterine tone and hemorrhage prevention.

A. Inform the client that oatmeal contains gluten. B. Encourage the client to choose decaffeinated coffee. C. Commend the client for selecting fat free milk. D. Advise the client that too much fruit can irritate the colon.

Correct Answer is A

Explanation

Choice A: Oatmeal is often considered a source of gluten, which should be avoided by individuals with celiac disease. The nurse should inform the client that oatmeal may not be suitable for a gluten-free diet.

Choice B: Encouraging the client to choose decaffeinated coffee is a minor consideration and is not the most important action related to celiac disease.

Choice C: Commending the client for selecting fat-free milk is unrelated to the issue of gluten in the oatmeal and is not the most important action.

Choice D: Advising the client about the potential irritant effects of too much fruit on the colon is not directly related to the issue of gluten in the oatmeal and is not the most important action.

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Following two defibrillation shocks, the client's electrocardiogram (ECG) continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman is brought to the labor and delivery unit after delivering a full term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first?

Correct Answer is A

Explanation

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

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