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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis (RA). A positive result supports the diagnosis of RA.
B. C-reactive protein is an inflammatory marker that is elevated in active RA, reflecting inflammation in the body.
C. Sedimentation rate (ESR) is also an inflammatory marker and is often elevated in RA, indicating active inflammation.
D. D-Dimer is a test that assesses for the presence of clot formation and breakdown. It is not used for diagnosing RA.
E. White blood cell count may be slightly elevated in RA due to inflammation, but it is not specific for RA and is less helpful in the diagnosis compared to the other tests.

A. Administer a PRN dose of regular insulin. B. Give the client 4 ounces (120 mL) of orange juice. C. Provide the client with 1/2 cup (120 mL) diet carbonated soda. D. Obtain blood pressure and heart rate. E. Check the client's current fingerstick blood glucose.

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

Explanation

A. Administering insulin would be inappropriate if the client is hypoglycemic, as it would further lower the blood glucose.

B. Giving 4 ounces (120 mL) of orange juice provides a fast-acting source of glucose to treat hypoglycemia, which is likely causing confusion and weakness.

C. A diet carbonated soda contains artificial sweeteners and may not provide the immediate glucose needed in this situation.

D. Checking blood pressure and heart rate is important to assess for potential causes of the symptoms.

E. A fingerstick blood glucose test is necessary to confirm if hypoglycemia is the cause of the symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

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

Explanation

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?