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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. The fall at home is part of the background information, but the immediate concern is the client’s changing mental status.
B. The sudden onset of increasing confusion and agitation could indicate a serious complication, such as delirium, infection, or a neurological issue. This is the priority to report to the healthcare provider.
C. While medication history is important, it is not as urgent as addressing the client’s current confusion.
D. The healthcare power of attorney is relevant for decision-making but not the first information needed in this urgent situation.

A. Prepare to administer warfarin B. Review last partial thromboplastin time (PTT) results. C. Assess characteristics of pain. D. Monitor stools for presence of blood E. Auscultate bowel sounds in all quadrants.

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

Explanation

A. Warfarin is not administered in this situation unless directed by a provider; the priority is addressing possible bleeding.
B. Reviewing the last PTT results is important to assess the effectiveness of heparin and monitor for potential bleeding complications.
C. Assessing the characteristics of pain can help determine if the client is experiencing gastrointestinal bleeding, which is a concern with heparin therapy.
D. Monitoring for blood in the stool is crucial, as tarry stools indicate possible gastrointestinal bleeding, a known complication of anticoagulation therapy.
E. Auscultating bowel sounds is important but does not directly address the potential complication of gastrointestinal bleeding, which is the priority in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

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

Explanation

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Exhibits According to the lab values, the client has dropdownrelated to dropdownordropdown.