Deck 30: Administering Emergency Measures to the Hospitalized Client

Question 1

The nurse enters the client's room and finds the client pulseless and not breathing.What tasks could the nurse safely assign to the unlicensed assistive personnel (UAP)in this situation?

A)Perform chest compressions.
B)Get the crash cart.
C)Call a code blue.
D)Administer emergency medications.
E)Bag the client using a bag-valve mask until the doctor arrives to intubate the client.

Answer 1

Perform chest compressions.
Get the crash cart.
Call a code blue.
Bag the client using a bag-valve mask until the doctor arrives to intubate the client.

Question 2

The nurse is attending a football game when another spectator reports chest pain and collapses.The nurse assesses the client and finds he is pulseless and not breathing.After the nurse calls for help,someone brings an AED.Which action by the nurse is the most appropriate?

A)Not using the device,because it needs to be plugged in and there is no electricity
B)Turning the machine on,placing the patches,and then plugging in the cable
C)Connecting the cables,placing the patches,and then turning on the machine
D)Placing the patches,turning on the machine,and then plugging in the cable

Answer 2

Turning the machine on,placing the patches,and then plugging in the cable

Question 3

For which client would the nurse not call the rapid response team?

A)Asthmatic client with a respiratory rate greater than 30 breaths per minute,oxygen saturation of 84%,and a heart rate of 142 beats per minute
B)A client with no history of seizures who has a sudden change in mentation and has a seizure
C)A client who suddenly begins to talk with difficulty and is not able to move the left arm and leg
D)The client with a history of angina who has a PRN order for nitroglycerin who reports crushing chest pain

Answer 3

The client with a history of angina who has a PRN order for nitroglycerin who reports crushing chest pain

Question 4

The nurse is called into the client's room by the family members,who report the client has stopped breathing.The nurse finds the client pulseless and not breathing.Which action by the nurse is the most appropriate in this situation?

A)Calling a code and asking the family to leave the room
B)Calling a code and providing the family with the option to leave the room
C)Calling a code and telling the family to stand out of the way
D)Calling a code and telling the family to ask any questions that might arise during the procedure

Question 5

The nurse is preparing to document care provided to a client who received rescue breathing while being transported to radiology.Which items will the nurse include in the documentation for this client?

A)Date and time of event
B)Factors that precipitated the event
C)Length of time with no breathing
D)Response to rescue breathing
E)Tasks assigned to the unlicensed assistive personnel

Question 6

When performing rescue breathing in a hospital,which is the preferred method for the nurse to use until the health care provider arrives to intubate the client?

A)Mouth-to-mouth
B)Mouth-to-mask
C)Bag-valve-mask method
D)The jaw-thrust maneuver

Question 7

While working on the orthopedic unit,the nurse finds an assigned client pulseless and not breathing.When the code team responds,which action by the nurse is appropriate?

A)Leaving the room and calling the family members to notify them of the sudden change in the client's condition
B)Getting the crash cart and emergency supplies that will be needed by the code team
C)Participating in the code in whatever role is necessary
D)Standing at the bedside and answering questions as they arise

Question 8

Following a code,the nurse assigned to the client will document the events.Which items should the nurse include along with the written documentation of the event?

A)The rhythm strip
B)The form used to record the medications and interventions that occurred during the code
C)The DNR record
D)Notification of the family
E)Client response and transfer location,if indicated

Question 9

The nurse working in the pediatric department of the hospital maintains competency by annually renewing which certification specific to the pediatric client?

A)ACLS
B)BCLS
C)PALS
D)CPR

Question 10

The nurse is caring for a conscious adult client with an obstructed airway.When performing abdominal thrusts,which action by the nurse is appropriate?

A)Making a fist with one hand,with the thumb on top,and placing the thumb just below the xiphoid process
B)Using the side of the hand and placing it just above the xiphoid process
C)Grasping the fist with the other hand and placing the flat of the hand into the client's abdomen
D)Making a fist with one hand,tucking the thumb inside the fist,grasping the hand with the other fist,and pushing the fist above the victim's navel and below the xiphoid process

Question 11

The nurse on a medical-surgical unit is caring for a client who complains of chest pain.Assessment findings include a blood pressure of 72/40,pulse rate of 40,and respiratory rate of 3 2.Which action by the nurse is the priority in this situation?

A)Calling a code
B)Calling the rapid response team
C)Calling the client's primary health care provider
D)Calling the emergency department (ED)and requesting they send a health care provider