When assisting with defibrillating an adult client who has gone into ventricular fibrillation, what must the nurse do?
Call “all clear” once before discharging the defibrillator
Maintain firm contact between paddles and client skin
Ensure the defibrillator is in the sync mode
Apply a layer of water as a conducting agent
The Correct Answer is B
Choice A rationale:
Calling "all clear" once before discharging the defibrillator is crucial for safety, but it's not the primary action that ensures effective defibrillation.
The purpose of calling "all clear" is to alert everyone in the vicinity to stay clear of the patient and avoid accidental shock.
However, even with a clear announcement, it's essential for the nurse to visually confirm that no one is touching the patient or bed before discharging the defibrillator.
Choice B rationale:
Maintaining firm contact between the paddles and the client's skin is essential for delivering the defibrillation shock effectively.
Here's a detailed breakdown of why this contact is so critical:
Maximizes energy transfer: Firm contact minimizes the impedance (resistance) between the paddles and the skin, allowing for the maximum amount of electrical energy to be transferred to the heart.
Reduces arcing: Arcing occurs when electrical energy jumps through the air instead of passing through the intended path (between the paddles and the heart). This can cause skin burns and reduce the effectiveness of the shock. Firm contact helps prevent arcing by ensuring a direct connection.
Ensures consistent current flow: Consistent contact ensures that the electrical current flows evenly across the chest, reaching all areas of the heart muscle. This increases the likelihood of successful defibrillation.
Minimizes energy loss: Any gaps or poor contact between the paddles and skin can lead to energy loss, reducing the shock's strength and effectiveness.
Choice C rationale:
Sync mode (synchronized cardioversion) is used for specific heart rhythm disturbances, such as atrial fibrillation or atrial flutter, where the shock needs to be timed with the QRS complex on the ECG.
Ventricular fibrillation, however, is a chaotic rhythm without distinct QRS complexes, so sync mode is not appropriate.
Using sync mode in ventricular fibrillation could delay the shock and potentially decrease its effectiveness.
Choice D rationale:
Water is not an appropriate conducting agent for defibrillation.
It can actually increase the risk of burns and decrease the effectiveness of the shock.
Approved conducting agents, such as gel pads or paste, should be used to ensure optimal energy transfer and patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The T wave specifically represents ventricular repolarization, which is the phase of the cardiac cycle when the ventricles return to their resting state after contraction. This is in contrast to the other waves on the ECG, which represent different phases of the cardiac cycle:
The P wave represents atrial depolarization, or the contraction of the atria.
The QRS complex represents ventricular depolarization, or the contraction of the ventricles.
The U wave, while less commonly seen, is thought to represent repolarization of the Purkinje fibers, which are specialized fibers that conduct electrical impulses through the ventricles.
The T wave is typically a smooth, rounded wave that follows the QRS complex. It is usually upright in most leads, but it can be inverted in certain leads, such as aVR.
The shape and duration of the T wave can provide important information about the health of the ventricles. For example, a flattened or inverted T wave can be a sign of myocardial ischemia (reduced blood flow to the heart muscle) or other heart problems.
It is important to note that the T wave does not represent the absolute resting state of the heart, as there is always some electrical activity occurring in the heart muscle. However, it is the closest representation of the resting state that is seen on the ECG.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Pain relief is a primary benefit of morphine administration in the setting of myocardial infarction.
Pain can trigger a stress response, leading to increased heart rate, blood pressure, and myocardial oxygen demand.
Morphine effectively reduces pain, thereby lessening the stress response and its detrimental effects on the heart.
This helps to minimize myocardial ischemia and potential further damage to the heart muscle.
Pain control also improves patient comfort and overall well-being, which can indirectly contribute to better cardiac outcomes.
Choice B rationale:
Sedation is another important benefit of morphine in this context.
It promotes rest and relaxation, which can lower heart rate, blood pressure, and myocardial oxygen demand.
This is crucial for patients with myocardial infarction, as their hearts require reduced workload to heal and recover.
Sedation also helps to alleviate anxiety and agitation, which can further strain the heart.
By inducing a state of calmness, morphine can indirectly protect the heart from additional stress.
Choice C rationale:
While morphine does have diuretic effects, increasing urinary output is not a primary goal in the management of myocardial infarction.
In fact, excessive diuresis could potentially lead to dehydration and hypotension, which could be detrimental to cardiac function.
Therefore, while morphine may slightly increase urine output, this is not a major reason for its use in this setting.
Choice D rationale:
Decreasing myocardial demand is a key benefit of morphine administration in patients with myocardial infarction.
Morphine achieves this by:
Reducing pain and the associated stress response
Promoting sedation and relaxation
Diminishing anxiety and agitation
Exerting a direct vasodilatory effect on blood vessels
This collective action of morphine leads to a decrease in heart rate, blood pressure, and the heart’s overall workload.
As a result, the heart requires less oxygen and experiences reduced strain, allowing for better healing and recovery following a myocardial infarction.
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