Question 1

The patient is brought to the emergency department following a motor vehicle accident.The patient has head and neck trauma and has stopped breathing.What should the nurse do?

Accepted Answer

Determine whether patient has spontaneous respirations.Consider spinal cord injury in patients with trauma.In these situations,a rescuer must use the jaw-thrust maneuver.Prevention of head extension and neck movement is very important to prevent paralysis or spinal cord injury.Apply a rigid cervical collar as soon as possible to reduce cervical spine motion.
Determine whether patient has spontaneous respirations first by opening the airway.

Question 2

The nurse finds a patient lying on the bathroom floor.The patient is unresponsive and has a pulse but is not breathing.What should the nurse do first?

Accepted Answer

Give 2 breaths using a mouth-to-mouth with barrier device or mouth-to-mask device or bag-mask device.Watch for chest rise and fall.In a hospital setting where protected methods of artificial ventilation are available,mouth-to-mouth without a barrier device is not recommended because of the risk for microbial contamination.
Watch for chest rise and fall.Motion,by itself,could be caused by fasciculation and is not indicative of air moving into and out of the chest.Airway always precedes circulation in the basic life support protocol.

Question 3

While measuring an oral airway for proper fit,the nurse places the airway so that the flange is held parallel to the front teeth with the airway against the patient's cheek.Where is the end of the curve?

Accepted Answer

Size is correct if,when the flange is held parallel to the front teeth with the airway against the patient's cheek,the end of the curve reaches the angle of the jaw.

Question 4

What is an advantage of the automated external defibrillator (AED)?

Accepted Answer

The advantage of the AED is that laypeople or health care providers trained in basic life support,who have less training than ACLS personnel,can defibrillate.
AEDs eliminate the training in rhythm interpretation and make early defibrillation practical and achievable.The AED is an automated external defibrillator that incorporates a rhythm analysis system.Upon rhythm identification,some AEDs will automatically provide the electrical shock after a verbal warning (fully automated).Other AEDs will recommend a shock,if needed,and then will prompt the responder to press the shock button.The provider does not need to adjust anything.

Question 5

The nurse is preparing to insert an oral airway in a patient who is exhibiting signs of potential respiratory distress.The nurse knows that candidates for oral airway placement are those:

Accepted Answer

Never insert an oral airway in a conscious patient or a patient with recent oral trauma,oral surgery,or loose teeth.Use oral airways only in unconscious patients.Oral airways may stimulate vomiting or laryngospasm if inserted in the semiconscious or conscious patient.

Question 6

The movement of oxygen and carbon dioxide into and out of the lungs is known as _____________________.

Accepted Answer

The answer of The movement of oxygen and carbon dioxide...

Question 7

At what rate do the 2005 American Heart Association (AHA)resuscitation guidelines recommend performing chest compressions?

Accepted Answer

The 2005 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute.

Question 8

Causes of a respiratory arrest include which of the following? (Select all that apply.)

Accepted Answer

Causes of a respiratory arrest include airway obstruction,cardiopulmonary illness,traumatic injury,and exposure to toxic substances.

Question 9

During the secondary survey of the code event,the nurse realizes that the patient is not breathing on his own.What should the nurse do next?

Accepted Answer

If respirations are absent,assist the code team with endotracheal intubation.Have available laryngoscope handle,curved and straight blades,endotracheal tubes,stylet,suction and tape,or ET tube holder.Ensure that the light source on the laryngoscope is functional.Light is necessary on the laryngoscope to visualize the vocal cords and intubate the trachea.Batteries may have to be changed.
Have available laryngoscope handle,curved and straight blades.

Question 10

Causes of dysrhythmia may include which of the following? (Select all that apply.)

Accepted Answer

Causes of dysrhythmia may include electrolyte disturbances (potassium,magnesium,calcium),heart damage,and certain prescribed or recreational medications.Early intervention for a respiratory arrest usually prevents a cardiac arrest.

Question 11

Which sign or symptom of airway compromise may require insertion of an oral airway?

Accepted Answer

Identify need to insert oral airway.Signs and symptoms include upper airway gurgling with breathing,absence of gag reflex,increased oral secretions,excessive drooling,grinding teeth,clenched teeth,biting of orotracheal or gastric tube,labored respirations,and increased respiratory rate.These conditions place the patient at risk for obstruction of the upper airway.
Normal response without evidence of airway obstruction or compromise.Wheezing may be present as symptom of allergy but not necessarily airway obstruction.

Question 12

An appropriate technique for a nurse to implement for oral airway insertion is to:

Accepted Answer

Hold oral airway with curved end up,insert distal end until airway reaches back of throat,then turn airway more than 180 degrees,and follow natural curve of tongue.
Never push the airway into position.Nurse may also hold airway sideways,insert halfway,and then rotate airway 90 degrees while gliding it over natural curvature of tongue (curved end down).

Question 13

The nurse is caring for an unconscious patient who has an oral airway in place,and who has copious amounts of oral secretions.What may the nurse have to do while caring for this patient? (Select all that apply.)

Accepted Answer

Do not use lemon glycerin swabs for oral care because they are drying to mucosal tissues and promote bacterial growth.The oral airway will have to be removed,cleaned or discarded,and replaced in patients with excessive oral secretions.Frequent suctioning of the oral cavity may be required.Oral airways are not a long-term solution.They can cause significant lip and tongue erosion.

Question 14

During a "code" situation,chest compressions should be interrupted for which of the following situations? (Select all that apply.)

Accepted Answer

The 2005 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute with few and very brief interruptions for ventilation,pulse checks,intubation,and defibrillation.

Question 15

When performing CPR on an adult patient who has an endotracheal tube in place,at what rate does the single rescuer administer breaths?

Accepted Answer

Rescue breaths for CPR with advanced airway (endotracheal tube/tracheotomy)are given at 8 to 10 breaths/min.

Question 16

What should the nurse do immediately after the anesthesiologist has intubated the patient in a code event? (Select all that apply.)

Accepted Answer

Assist in confirmation of endotracheal tube placement by auscultating epigastric area for lack of breath sounds and then the lungs for bilateral breath sounds.Intubation personnel usually perform secondary confirmation by using a carbon dioxide detector.Ventilate using a bag-mask device upon intubation at a rate of 8 to 10 breaths per minute.Avoid hyperventilation.Increased intrathoracic pressure due to incomplete exhalation results in reduced cardiac output.Chest radiograph usually is obtained after patient has been stabilized to confirm placement of endotracheal tube and central venous catheters.

Question 17

How deep should chest compressions be when CPR is administered to a pulseless adult?

Accepted Answer

Chest compressions for an adult are done on the lower half of the sternum between the nipples,with the heel of one hand and with the other hand on top compressing 1½ to 2 inches.
½ to 1 inch and 1 to 1½ inches is no longer recommended.For children or infants,the recommendation is 1/3 to ½ the depth of the chest.2½ to 3 inches is too deep for the average adult. is no longer recommended.

Question 18

The nurse is working in the emergency department when an 8-year-old patient is brought in with respiratory distress.The nurse is preparing to insert an oral airway.Which of the following is the appropriate size for this patient?

Accepted Answer

Oral airways vary in length and width.Pediatric sizes are 000,00,0,1,2,and 3 centimeters.School-age children are usually size 3 or 4.Adult sizes are 4 through 10 or small,medium,and large.The nurse chooses the size of an oral airway based on the patient's age and the width and length of the patient's mouth.
Pediatric sizes are 000,00,0,1,2,and 3 centimeters.School-age children are usually size 3 or 4.Adult sizes are 4 through 10 or small,medium,and large.

Question 19

_______________ is the movement of oxygen and carbon dioxide into and out of cells and tissues.

Accepted Answer

The answer of _______________ is the movement of oxygen and...

Question 20

The patient was defibrillated during a cardiopulmonary arrest and is in a normal heart rhythm but still is not breathing on his own.The patient is placed on a ventilator,and the physician orders that the patient be "cooled down" using an external cooling device to help preserve neurological function.The nurse realizes that the goal is to lower the patient's body temperature to:

Accepted Answer

Lowering the body temperature to 33° C (91.4° F)has improved the neurological recovery of out-of-hospital,postventricular fibrillation arrest victims.
37º C is the average oral/tympanic temperature and is considered "normal," and would not be cool enough for this situation.36.5º C is the average axillary temperature and would not be cool enough to affect neurological functioning.37.5º C is the average rectal temperature and is considered "normal," and would not be cool enough for this situation.

Quiz 27: Emergency Measures for Life Support