Difficulty: Medium
Average Score: 87%
Simulated
During an emergency code situation, a primary health care provider about to defibrillate a client diagnosed in ventricular fibrillation says in a loud voice, 'CLEAR!' Which action should the nurse immediately implement?
Correct answer
D
Rationale
For the safety of all personnel, when the defibrillator paddles are being discharged, all personnel must stand back and be clear of all contact with the client or the client's bed. It is the primary responsibility of the person defibrillating to communicate the 'clear' message loudly enough for all to hear and ensure their compliance. All personnel must immediately comply with this command. Stepping back from the bed prevents the nurse or others from being defibrillated along with the client. A ventilator is not in use during a code; rather, an Ambu (resuscitation) bag is used. Shutting off the intravenous infusion has no useful purpose. The gel pads should have been placed on the client's chest before the defibrillator paddles were applied.