A nurse is caring for a client in the ICU who has a history of cardiac dysrhythmias. The client goes into a state of ventricular tachycardia, and the nurse is unable to find a pulse. The code team arrives and delivers a shock of defibrillation to the client at 150 Joules. Which step would the nurse perform next?

Provide two manual breaths with a bag and mask.

Assess the client’s pulse.

Immediately resume chest compressions.

Administer 1 mL of IV epinephrine.

Answer and Explanation

The Correct Answer is C

Choice A reason: Providing breaths follows compressions in ACLS after defibrillation for pulseless ventricular tachycardia. Resuming compressions is immediate, making this incorrect, as it delays the nurse’s priority to restore circulation post-shock in the client’s code situation.

Choice B reason: Assessing the pulse occurs after 2 minutes of compressions, not immediately post-defibrillation. Resuming compressions is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on continuing CPR in pulseless ventricular tachycardia.

Choice C reason: Resuming chest compressions immediately after defibrillation maintains circulation in pulseless ventricular tachycardia per ACLS guidelines. This aligns with code management, making it the correct next step for the nurse to perform to optimize the client’s resuscitation efforts.

Choice D reason: Epinephrine is given after the second shock or per protocol, not immediately post-defibrillation. Compressions are the priority, making this incorrect, as it’s not the next step in the nurse’s ACLS sequence for managing the client’s arrhythmia.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Flushing with 15 mL water between medications is correct to prevent clogging and ensure delivery. Immediate feeding reconnection risks phenytoin absorption, making this incorrect, as it’s a proper action unlike the error requiring the nurse’s immediate intervention.

Choice B reason: Reinserting 50 mL of aspirated stomach contents is acceptable to maintain fluid balance. Reconnecting feeding immediately affects phenytoin efficacy, making this incorrect, as it’s a correct action compared to the student’s error needing the nurse’s urgent correction.

Choice C reason: Checking gastric aspirate pH confirms tube placement, a safety step. Immediate feeding reconnection reduces phenytoin absorption, making this incorrect, as it’s a proper action unlike the student’s mistake requiring the nurse’s immediate intervention for medication administration.

Choice D reason: Reconnecting enteral feeding immediately after phenytoin reduces its absorption, as feedings should be held for 1-2 hours. This requires immediate intervention, aligning with medication administration protocols, making it the correct action for the nurse to address in the student’s care.

A. This is a normal, expected event. B. The client is experiencing early signs of ischemic bowel. C. The client should not have the nasogastric tube removed. D. This indicates inadequate preoperative bowel preparation.

Correct Answer is A

Explanation

Choice A reason: Malodorous flatus 2 days post-colostomy is normal, indicating bowel function resumption. This aligns with postoperative colostomy expectations, making it the correct interpretation by the nurse, as flatus is an expected milestone in the client’s recovery process.

Choice B reason: Ischemic bowel causes pain, fever, or absent output, not just malodorous flatus, which is normal post-colostomy. This is incorrect, as it misinterprets a typical finding as a serious complication in the nurse’s assessment of the client’s stoma.

Choice C reason: Flatus doesn’t indicate the need for a nasogastric tube, which is used for obstruction or ileus. Normal flatus is expected, making this incorrect, as it wrongly suggests intervention for a typical post-colostomy finding in the nurse’s evaluation.

Choice D reason: Malodorous flatus is unrelated to preoperative bowel preparation; it’s a normal post-colostomy event. This is incorrect, as it misattributes a standard recovery sign to surgical preparation, unlike the nurse’s correct interpretation of expected bowel function.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

Correct Answer is A

Explanation

A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

A home health nurse is assessing a client who requires lifelong replacement hormone therapy for hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

The nurse notes that a client’s T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?