During an emergency code situation, a primary healthcare provider about to defibrillate a client diagnosed with ventricular fibrillation says in a loud voice, "CLEAR!" Which action should the nurse implement immediately?

Verify the conductive gel pads to ensure proper placement

Step away from the bed and make sure all others have done the same

Shut off the intravenous infusion going into the client's arm

Shut off the mechanical ventilator

Answer and Explanation

The Correct Answer is B

Choice A reason: Verifying the conductive gel pads is important but should be done before the command "CLEAR!" is given.

Choice B reason: Stepping away from the bed and ensuring others have done the same is crucial for safety. It prevents accidental electrical shock to anyone touching the patient or bed during defibrillation.

Choice C reason: Shutting off the intravenous infusion is not necessary during defibrillation. It does not pose a safety risk in this context.

Choice D reason: Shutting off the mechanical ventilator is not necessary during defibrillation and could compromise the patient's ventilation status.

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Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings and validates their experience. It opens the door for the client to express their emotions and share their thoughts. This empathetic approach helps build trust and provides emotional support.

Choice B reason: Telling the client that it takes time to get over the loss of a loved one is a generalized statement that may not provide the support the client needs. It can come across as dismissive and may not encourage further conversation.

Choice C reason: Suggesting that the client try something to take their mind off their troubles can seem dismissive of their grief. It does not address the client's emotional needs or encourage them to talk about their feelings.

Choice D reason: While this response shows some understanding, it does not fully acknowledge the uniqueness of the client's situation. It is important to validate the client's feelings and encourage them to express their emotions.

A. Are you taking any medications? B. Have you had a recent infection? C. Have you traveled overseas? D. Do you have a history of chronic alcohol abuse?

Correct Answer is B

Explanation

Choice A reason: While knowing if the client is taking any medications is important, it does not directly relate to diagnosing Guillain-Barré syndrome.

Choice B reason: Guillain-Barré syndrome often follows a recent infection, such as a respiratory or gastrointestinal infection. The immune response to the infection can trigger an autoimmune reaction that damages the peripheral nerves, leading to the symptoms of GBS. Therefore, asking about recent infections helps establish a potential cause for the syndrome.

Choice C reason: Travel history can be relevant for certain infectious diseases, but it is not a primary question for diagnosing GBS.

Choice D reason: A history of chronic alcohol abuse is more relevant to other neurological conditions, such as peripheral neuropathy, but not specifically to Guillain-Barré syndrome.

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During an emergency code situation, a primary healthcare provider about to defibrillate a client diagnosed with ventricular fibrillation says in a loud voice, "CLEAR!" Which action should the nurse implement immediately?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

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