Question 1

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose.  Which action would be appropriate?

Accepted Answer

Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress (Option C). (Option A) GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. (Option B) During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. (Option D) GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards. Educational objective: Gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose. It should be initiated within one hour of overdose. The nurse should position the client to prevent aspiration and have emergency respiratory equipment at the bedside.

Question 2

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client. Which of the following actions by a resuscitation team member would cause the charge nurse to intervene? Select all that apply.

Accepted Answer

All members of the health care team must follow basic life support guidelines to perform cardiopulmonary resuscitation (CPR) for clients experiencing cardiac arrest. Essential components of adult CPR include: Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions (Option A).Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line (Option C). Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions (Option A). Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions (Option A). Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line (Option C). Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line (Option C). (Option B) During CPR, compressions are paused every 2 minutes to assess the client's pulse. This pause should be no longer than 10 seconds to minimize delays between compression cycles. (Option D) Manual breaths are administered at a rate of 2 breaths per 30 chest compressions in clients without advanced airways or once every 6 seconds without chest compression interruption with advanced airway placement. (Option E) The team member managing the defibrillator should use firm verbal cues (eg, "stand clear!") to clear all team members from contact with the client, followed by visual confirmation before defibrillation. Educational objective: During cardiopulmonary resuscitation, chest compressions are performed at a rate of 100-120/min. Defibrillator pads are placed on the right upper chest and on the left lateral chest.

Question 3

The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and there are no other caregivers present. Which action should the nurse take first?

Accepted Answer

Cardiac arrest is the sudden cessation of cardiac output that is usually caused by an arrhythmia. Arrest can be precipitated by a variety of factors (eg, hypoxia, toxins, electrolyte imbalance) and is a medical emergency. In children, cardiac arrest is commonly caused by hypoxia and respiratory failure. If the nurse is a single rescuer in a witnessed cardiac arrest of a pediatric client, the first action is to promptly initiate CPR, starting with chest compressions (Option A). For the pediatric client, initiating CPR before other interventions (eg, calling 911) helps minimize risk for end organ damage and brain injury. The nurse should provide 30 chest compressions and 2 rescue breaths in each cycle of CPR. (Option B) For a client with a tracheostomy tube and mechanical ventilator, the nurse should disconnect the client from the ventilator and give rescue breaths using a bag valve device. However, the nurse should first initiate chest compressions. (Options C and D) If the nurse is still alone after 2 minutes (~5 cycles) of CPR, it is appropriate to pause CPR to activate the emergency response system and obtain the automated external defibrillator, if available. Educational objective: Cardiac arrest, the sudden cessation of cardiac output, is a medical emergency. If a single rescuer witnesses cardiac arrest in a pediatric client, the rescuer should immediately begin CPR (starting with chest compressions) for 2 minutes (~5 cycles) before activating the emergency response system and obtaining an automated external defibrillator.

Question 4

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply.

Accepted Answer

Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and respiratory distress. To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa (Option B). Oral care is provided to decrease bacteria and contaminants as well as promote comfort (Option D). Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis (Option E). (Options A and C) Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside swallow screen or a more formal swallow evaluation by a speech therapist prior to swallowing any food, drink, or medication. Educational objective: Recently extubated clients are immediately placed on humidified oxygen and monitored for aspiration, airway obstruction, and respiratory distress. Clients should remain NPO until swallowing function has been evaluated. In addition, clients should be given routine oral care as well as instructions on coughing, deep breathing, and use of incentive spirometry.

Question 5

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education?

Accepted Answer

11ecbb05_cb0d_c2b3_b433_e1412ff933da_MD0009_00 Endotracheal (ET) suctioning improves ventilation in mechanically ventilated clients by removing mucus and secretions from the ET tube. Suctioning is performed based on clinical findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or signs of acute respiratory distress. Frequent suctioning increases the risk of tracheal and bronchial trauma, bleeding, and hypoxia. Suctioning should be performed only when needed to reduce the risk for injury (Option B). (Option A) Auscultating the neck to monitor for an ET tube cuff leak is a standard component of respiratory assessment in mechanically ventilated clients. The presence of a cuff leak increases the risk of accidental extubation, impairs ventilation, and allows aspiration of secretions from the mouth and throat. (Option C) Oral care with oral suctioning is performed every 2 hours to prevent ventilator-associated pneumonia (VAP). Secretions in the mouth and throat often contain bacteria that can cause pneumonia. (Option D) Repositioning clients at least every 2 hours reduces the occurrence of VAP. Turning clients side-to-side promotes mobilization of secretions and prevents secretions from pooling in dependent areas of the lungs. Educational objective: Endotracheal suctioning in mechanically ventilated clients should be performed based on assessment findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or acute respiratory distress. Suctioning should be performed only when needed to reduce the risk of lung trauma and hypoxia.

Question 6

The nurse observes a nursing student performing chest compressions on an adult client.  Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation?

Accepted Answer

11ecbb05_cb0c_3c11_b433_dd245c373261_MD0009_00 The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option A). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. (Option B) Interruption of compressions should be minimized; at least 60% (preferably more) of the total resuscitation time should be made up of compressions. For adults (and in single-rescuer CPR for any age), a cycle of 30 compressions followed by 2 rescue breaths provides the best outcome. If the client has an advanced airway, continuous compressions and 10 breaths/min should be provided. (Option C) Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone). Hand placement on the upper half of the sternum does not provide adequate perfusion. (Option D) Studies have shown better client outcomes due to improved perfusion with a compression rate of 100-120/min. Educational objective: For high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths).

Question 7

The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury?

Accepted Answer

11ecbb05_cb0a_b66f_b433_6f1f27db1a89_MD0009_00 Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. (Option A) Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia will eventually lead to organ failure, making this an urgent finding but not initially life-threatening. (Option C) A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. Sometimes the client is so cold that a pulse cannot be detected; this is why a client is not dead until warm and dead. Such clients may require prolonged resuscitation. (Option D) When wheezing is heard on auscultation after a near-drowning, the first observation would be that the client is still moving air and providing oxygen to the body. The wheezing may indicate that the client has bronchospasm. If the client has aspirated fluid, crackles would be heard. Most such clients will develop acute respiratory distress syndrome. Educational objective: Decerebrate posturing (arms and legs straight out, toes pointed down, head/neck arched back) usually indicates severe brain injury.

Question 8

A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention?

Accepted Answer

Clients with paroxysmal supraventricular tachycardia (SVT) (regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement (Valsalva) is an example of these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the atrioventricular node. (Option B) Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and briefly allowing a normal heartbeat to return. (Option C) An ECG is used to diagnose SVT and can be obtained while or after the client is asked to perform the vagal maneuvers as it is not therapeutic. (Option D) Adenosine is the drug of choice to treat SVT and has a 5- to 6-second half-life (the time it takes for the drug to be reduced to half of its original concentration). Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-mL normal saline flush. Transient asystole is common, and clients often experience flushing and dizziness. Educational objective: Supraventricular tachycardia is a regular, narrow QRS complex tachycardia with a rate of around 150-220/min. The best treatment is vagal maneuvers and adenosine IV push.

Question 9

The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first?

Accepted Answer

A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well. (Option B) Hyper-oxygenating would not increase ventilation if the tube is not in proper position or if the client has a pneumothorax. (Option C) The first step is to confirm tube placement. Manually ventilating through a displaced tube would produce no better results than use of the ventilator. (Option D) Mucus plugs are a common cause of decreased oxygen saturation in the intubated client. There are, however, specific symptoms associated with this problem, including secretions backing up in the tube and high-pressure ventilator alarms. Although this client may still need suctioning even if these symptoms are not present, auscultating lung sounds is necessary to confirm tube placement before suctioning. Suctioning via a displaced tube could cause additional damage to the client's airway. Educational objective: Proper placement of the endotracheal tube is essential for adequate ventilation in intubated clients. If the tube becomes displaced in the hypopharynx, hypoxemia can result. Confirming the presence of equal breath sounds bilaterally via auscultation is an important initial nursing intervention.

Question 10

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest.  The client does not follow commands and remains comatose.  What intervention does the nurse anticipate being added to the client's plan of care?

Accepted Answer

Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated in all clients who are comatose or do not follow commands after resuscitation. The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is slowly rewarmed. (Option A) It is too early to consider a do-not-resuscitate order. If the client does not respond to therapeutic hypothermia or there is evidence of neurologic impairment, it may be discussed at some point. (Option C) Clients are generally kept NPO during therapeutic hypothermia and rewarming. The feeding tube may be needed after that time. (Option D) Passive range-of-motion exercises would be indicated for this client but are not the immediate priority. Educational objective: Following return of spontaneous circulation in an out-of-hospital cardiac arrest, therapeutic hypothermia should be implemented for 24 hours in clients who are comatose or do not follow commands. Therapeutic hypothermia has been shown to improve neurologic outcomes and decrease mortality in these clients.

Question 11

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse.  CPR is initiated.  When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads.  What is the appropriate action at this time?

Accepted Answer

11ecbb05_cb0b_51b0_b433_5765f4fe645c_MD0009_00 An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart"). (Option A) If an AED is available, it should be placed on the client as soon as possible. Research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest. (Option C) Standard placement of adult AED pads on a 2-year-old would cause the pads to touch or overlap. Touching or overlapping of pads allows the shock to move directly from one pad to the other without traveling through the heart. (Option D) Both AED pads are necessary for the defibrillator to work effectively. Educational objective: An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

Question 12

A nurse is caring for a client on a mechanical ventilator. The ventilator is sounding an alarm and displaying an alert about low tidal volumes. The nurse has checked all connections and the endotracheal tube, but the alarm persists and the client's oxygen saturation is dropping. What should the nurse do next?

Accepted Answer

11ecbb05_cb0c_b142_b433_ab25655ae62c_MD0009_00 A low tidal volume alarm indicates that the volume of air the ventilator is delivering is lower than the set volume. This is most often due to a disconnection, loose connection, or leak in the circuit. The nurse should troubleshoot the most common causes of the alarm, but if the client's condition is deteriorating clinically (eg, decreasing oxygen saturation), then the nurse should disconnect the ventilator and manually ventilate the client's lungs with a resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state can be resolved. (Option A) Respiratory therapists have specialized training in mechanical ventilators. They should be called to the bedside but only after the nurse has begun to stabilize the client's condition using manual ventilation. (Option B) Since the client is intubated, air cannot pass from the nares and oropharynx into the lungs, and ventilation can be achieved only via the endotracheal tube. (Option C) The client would benefit from a higher oxygen level, but the ventilator is unable to deliver the programmed volume to the client, even with an increased oxygen level. The client's lungs must be manually ventilated with a resuscitation bag. Educational objective: Ventilators may sound an alarm when set parameters are not being met (eg, low tidal volumes, high peak pressures). These alarms may indicate a client condition or ventilator malfunction. If a ventilator alarm cannot be readily resolved, the nurse should manually ventilate the client's lungs with a resuscitation bag device.

Exam 3: Critical Care

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client. Which of the following actions by a resuscitation team member would cause the charge nurse to intervene? Select all that apply.

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply.

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education?

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation?

The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury?

A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention?

The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first?

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care?

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?