HESI RN Exit Proctored Exam
A client with a permanent pacemaker has no pulse or spontaneous respirations and the monitor is displaying a ventricular fibrillation rhythm. Resuscitation is in progress and the nurse is preparing to defibrillate the client with 200 joules of unsynchronized defibrillation. Which intervention is most important for the nurse to implement?
Explanation & Rationale
A. Obtaining a 12-lead ECG is done after return of spontaneous circulation (ROSC), not during defibrillation. B. Interrogating the pacemaker is important but is not the immediate priority during resuscitation. C. Defibrillator pads should be placed at least 1 inch away from the pacemaker to prevent damage to the device and ensure effective defibrillation. D. A doughnut magnet is used to deactivate pacemaker functions in cases like pacemaker-mediated tachycardia but is not relevant in ventricular fibrillation.
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