When assisting with defibrillating an adult client who has gone into ventricular fibrillation, what must the nurse do?

Call “all clear” once before discharging the defibrillator

Maintain firm contact between paddles and client skin

Ensure the defibrillator is in the sync mode

Apply a layer of water as a conducting agent

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Calling "all clear" once before discharging the defibrillator is crucial for safety, but it's not the primary action that ensures effective defibrillation.

The purpose of calling "all clear" is to alert everyone in the vicinity to stay clear of the patient and avoid accidental shock.

However, even with a clear announcement, it's essential for the nurse to visually confirm that no one is touching the patient or bed before discharging the defibrillator.

Choice B rationale:

Maintaining firm contact between the paddles and the client's skin is essential for delivering the defibrillation shock effectively.

Here's a detailed breakdown of why this contact is so critical:

Maximizes energy transfer: Firm contact minimizes the impedance (resistance) between the paddles and the skin, allowing for the maximum amount of electrical energy to be transferred to the heart.

Reduces arcing: Arcing occurs when electrical energy jumps through the air instead of passing through the intended path (between the paddles and the heart). This can cause skin burns and reduce the effectiveness of the shock. Firm contact helps prevent arcing by ensuring a direct connection.

Ensures consistent current flow: Consistent contact ensures that the electrical current flows evenly across the chest, reaching all areas of the heart muscle. This increases the likelihood of successful defibrillation.

Minimizes energy loss: Any gaps or poor contact between the paddles and skin can lead to energy loss, reducing the shock's strength and effectiveness.

Choice C rationale:

Sync mode (synchronized cardioversion) is used for specific heart rhythm disturbances, such as atrial fibrillation or atrial flutter, where the shock needs to be timed with the QRS complex on the ECG.

Ventricular fibrillation, however, is a chaotic rhythm without distinct QRS complexes, so sync mode is not appropriate.

Using sync mode in ventricular fibrillation could delay the shock and potentially decrease its effectiveness.

Choice D rationale:

Water is not an appropriate conducting agent for defibrillation.

It can actually increase the risk of burns and decrease the effectiveness of the shock.

Approved conducting agents, such as gel pads or paste, should be used to ensure optimal energy transfer and patient safety.

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Correct Answer is E

Explanation

Choice A rationale:

While aspirin can help improve heart function in certain cases, such as by reducing inflammation, it's not accurate to say it directly restores normal heart function. This statement oversimplifies aspirin's mechanism of action and could mislead the client.

It's essential to emphasize aspirin's role in preventing clots, which is the primary reason for its use in coronary artery disease.

Choice B rationale:

Aspirin does not affect the oxygen-carrying capacity of blood. This function is primarily carried out by hemoglobin in red blood cells.

Stating that aspirin increases oxygen-carrying capacity could create misunderstandings about its role in coronary artery disease.

Choice C rationale:

Aspirin does not directly make blood penetrate the heart more freely. Its action primarily involves preventing blood clots from forming within blood vessels.

This statement could lead to a misconception about aspirin's mechanism of action, potentially affecting adherence to treatment.

Choice D rationale:

This is the most accurate and comprehensive response. It directly addresses the client's question and highlights the primary reason for daily aspirin use in coronary artery disease.

Aspirin inhibits platelet aggregation, reducing the risk of blood clots that can obstruct coronary arteries and trigger heart attacks or chest pain.

By preventing these blockages, aspirin can help prevent future cardiovascular events and improve the client's overall health outcomes.

A. Drowsiness or blurred vision B. Nervousness or paresthesia C. Throbbing headache and dizziness D. Tinnitus or diplopia E. Tinnitus or diplopia

Correct Answer is C

Explanation

Choice A rationale:

Drowsiness and blurred vision are not common adverse effects of nitroglycerin.

While some individuals may experience mild drowsiness, it's not a primary concern.

Blurred vision is not typically associated with nitroglycerin use.

Choice B rationale:

Nervousness and paresthesia (tingling or numbness in the extremities) are not common adverse effects of nitroglycerin.

Some individuals may experience transient anxiety or nervousness, but it's not a characteristic side effect.

Paresthesia is more commonly associated with other medications or conditions.

Choice C rationale:

Throbbing headache and dizziness are the most common adverse effects of nitroglycerin.

They occur due to nitroglycerin's vasodilatory effect, which causes blood vessels to relax and widen.

This can lead to a temporary drop in blood pressure, resulting in headaches and dizziness.

The headaches are often described as throbbing or pulsating, and they typically occur in the frontal or temporal regions of the head.

Dizziness may be mild or severe, and it may be accompanied by lightheadedness or a feeling of unsteadiness.

Choice D rationale:

Tinnitus (ringing in the ears) and diplopia (double vision) are not common adverse effects of nitroglycerin.

They may occur in rare cases, but they are not typically associated with its use.

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When assisting with defibrillating an adult client who has gone into ventricular fibrillation, what must the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why he has to take an aspirin every day if he doesn’t have any pain. What would be the nurse’s best response?

Correct Answer is E

Explanation

A client with angina has been prescribed nitroglycerin. Before administering the drug, what potential adverse effects should the nurse inform the client about?

Correct Answer is C

Explanation

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