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 B

Explanation

Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.

Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.

Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.

Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.

A. Comprehension of simple commands. B. Exploration beyond caregiver presence. C. Visible or audible separation anxiety. D. Ability to place objects in a container.

Correct Answer is B

Explanation

Choice A: Comprehension of simple commands is an earlier developmental stage and not directly related to the infant's ability to search for a fallen toy.

Choice B: Exploration beyond caregiver presence is a key characteristic of the sensorimotor stage in Piaget's theory. During this stage, infants develop object permanence and begin to explore their environment independently.

Choice C: Visible or audible separation anxiety is common during the early stages of infancy and is not specific to the sensorimotor stage.

Choice D: The ability to place objects in a container is more related to later developmental stages when fine motor skills are more developed.

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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

An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Correct Answer is B

Explanation

The practical nurse (PN) observes an infant searching for a fallen toy. According to Piaget, which additional finding should the PN correlate with this developmental stage?

Correct Answer is B

Explanation

Which statement by an adolescent client with acute osteomyelitis in the right leg indicates the best understanding of the appropriate activity level after discharge?

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The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

The healthcare provider prescribes amoxicillin-clavulanic acid suspension 300 mg by mouth (PO) three times daily (TID) for a child with a lower respiratory infection. The bottle is labeled," 250 mg/5 mL. How many mL should the nurse administer in a single dose? (Enter numeric value only.)

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