A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client?
Test the equipment by delivering a smaller shock at 50 J.
Administer 2 mg of intravenous epinephrine.
Make sure that the defibrillator is set to the synchronous mode.
Ensure that everyone is clear of contact with the client and the bed.
The Correct Answer is D
A. Testing the equipment with a smaller shock is unnecessary when preparing to defibrillate in an emergency.
B. Epinephrine is used in cases of cardiac arrest with no pulse, particularly in asystole or pulseless electrical activity (PEA), not immediately before defibrillation in ventricular fibrillation.
C. Synchronous mode is used for cardioversion, not for defibrillation. Defibrillation should be delivered in unsynchronized mode.
D. Before delivering a shock, it is essential to ensure that everyone, including the nurse, is clear of the client and any conductive surfaces like the bed. This prevents injury from the electrical shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tight shoes may indicate fluid retention in the lower extremities, which is a common symptom of right-sided heart failure. This condition leads to the backup of blood into the systemic circulation, causing peripheral edema.
B. Sleeping with two pillows may indicate left-sided heart failure, as the client may be experiencing orthopnea (difficulty breathing when lying flat).
C. Shortness of breath is more commonly associated with left-sided heart failure.
D. Waking up coughing every night is also a sign of left-sided heart failure, where pulmonary congestion leads to nocturnal coughing.
Correct Answer is D
Explanation
A. Administering multiple vitamins and minerals via IV alone would not be sufficient for adequate nutrition in this patient, especially given the large burn surface area.
B. Total parenteral nutrition (TPN) may be used if enteral feeding is not possible, but enteral feeding is usually preferred when feasible.
C. Encouraging oral intake is not appropriate for a client with a 60% TBSA burn, as they would likely require more significant nutritional support than oral intake can provide.
D. Enteral feeding is the preferred method for nutrition in burn patients as it maintains gut integrity and prevents the complications associated with parenteral nutrition. Although the client has absent bowel sounds and a distended abdomen, this can be common early in burn care, and enteral feedings should be started as soon as feasible to prevent malnutrition and promote recovery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.