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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Correct Answer is D

Explanation

Choice A reason: Suction pressure at -20 cmH2O is standard for chest tubes and not an immediate concern. Continuous bubbling suggests a pneumothorax, making this incorrect, as it’s a normal setting compared to the priority of addressing a potential air leak in the system.

Choice B reason: Bubbling in the drainage tubing is normal with fluid movement, not indicating an issue. Continuous bubbling in the chamber suggests an air leak, making this incorrect, as it’s less urgent than the priority client with a potential pneumothorax requiring immediate assessment.

Choice C reason: A drainage system on the floor risks tipping but is less urgent than continuous bubbling indicating an air leak. The pneumothorax risk takes precedence, making this incorrect, as it’s a secondary issue compared to the priority client’s chest tube complication.

Choice D reason: Continuous bubbling in the drainage chamber suggests an air leak or pneumothorax, a critical complication requiring immediate assessment. This aligns with chest tube management priorities, making it the correct client for the nurse to see first to address a potential emergency.

A. Stoma is beefy red and shiny. B. Purple discoloration of the stoma. C. Skin excoriation around the stoma. D. Semiformed stool noted in the ostomy pouch.

Correct Answer is B

Explanation

Choice A reason: A beefy red, shiny stoma is normal, indicating healthy tissue perfusion. Purple discoloration suggests ischemia, making this incorrect, as it doesn’t require immediate notification compared to the nurse’s priority of reporting a potentially life-threatening stoma complication to the provider.

Choice B reason: Purple discoloration of the stoma indicates potential ischemia or necrosis, a serious complication requiring immediate provider notification. This aligns with colostomy care priorities, making it the correct observation for the nurse to report promptly to prevent further tissue damage or obstruction.

Choice C reason: Skin excoriation around the stoma is concerning but less urgent than purple discoloration, which signals ischemia. This is incorrect, as it can be managed with barrier creams, unlike the nurse’s priority of addressing a critical stoma issue requiring immediate intervention.

Choice D reason: Semiformed stool in the ostomy pouch is expected post-colostomy and not alarming. Purple discoloration is critical, making this incorrect, as it’s a normal finding compared to the nurse’s need to notify the provider about a potentially ischemic stoma.

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Naxlex Comprehensive Predictor Exams

A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

Correct Answer is D

Explanation

The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider?

Correct Answer is B

Explanation

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?

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia?

A client returns to the unit immediately following a cardiac catheterization. Which action by the nurse is MOST important?

The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?