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.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.

Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.

Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.

A. Finish the procedure. B. Call for an assistant. C. Respond to the code. D. Close the room door.

Correct Answer is B

Explanation

A. Completing the procedure would delay the nurse’s response to the emergency.

B. Calling for an assistant allows the nurse to quickly respond to the emergency while ensuring that the tracheostomy care is not neglected.

C. Responding to the code is the priority, but assistance should be called to ensure that other duties are attended to in the meantime.

D. Closing the room door would isolate the situation but does not address the immediate need for assistance.

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Naxlex Comprehensive Predictor Exams

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

Explanation

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?

Correct Answer is B

Explanation

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

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.

Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Which client should the charge nurse on the oncology unit assign to a registered nurse (RN), rather than a practical nurse (PN)?

Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has dropdownas evidenced by dropdownanddropdown.

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?