Question 1

The nurse sees on the cardiorespiratory monitor that the patient's cardiac rhythm has changed from normal sinus rhythm to ventricular fibrillation.The nurse knows that the most effective means of converting this rhythm is:

Accepted Answer

Cardiopulmonary resuscitation (CPR)should be performed until the defibrillator patches are applied,but it is not the most effective means of converting the electrical rhythm;rather it supports life until defibrillation can be performed.Oxygen should be administered during CPR,but it is not the means of converting the rhythm.Precordial thumps are controversial at best and would not be the most effective means of converting the rhythm.

Question 2

The nurse would call the code team for which of the following patients?

Accepted Answer

A patient who becomes unconscious while in ventricular tachycardia requires the rapid intervention of the cardiac/respiratory arrest team.A hypotensive patient or a patient experiencing dyspnea requires the intervention of the rapid response team.A patient in atrial fibrillation requires notification of the primary care provider.

Question 3

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

Accepted Answer

Identify the need to insert an oral airway.Signs and symptoms include upper airway gurgling with breathing,absence of a gag reflex,increased oral secretions,excessive drooling,grinding of teeth,clenched teeth,biting of the 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 shows no evidence of airway obstruction or compromise.Wheezing may be present as a symptom of allergy but not necessarily of airway obstruction.

Question 4

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 5

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

Accepted Answer

First determine whether the patient has spontaneous respirations by opening the airway.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.

Question 6

The nurse is performing cardiopulmonary resuscitation (CPR)on an adult patient who has an endotracheal tube in place.At what rate does the nurse,who is alone,administer breaths?

Accepted Answer

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

Question 7

The nurse enters the patient's room and finds that the patient is not breathing and has no pulse.The patient does not have a do-not-resuscitate order.What would the nurse's most immediate action be?

Accepted Answer

The nurse's first action should be to summon the cardiac/respiratory arrest team because it will take them a few minutes to arrive,and the patient's best outcome depends on their rapid arrival.As soon as the team has been called,the nurse should begin cardiopulmonary resuscitation (CPR).If the arrest is not called over the public address system,the nurse should call a co-worker for help while performing CPR or after initiating CPR.If the code is called over the public address system,co-workers will hear the call and will come to the room without being summoned.Once co-workers have been alerted,they can obtain the crash cart and summon additional support.

Question 8

The nurse is providing cardiopulmonary resuscitation (CPR)to an unresponsive patient according to the 2010 American Heart Association (AHA)resuscitation guidelines.The nurse is performing chest compressions correctly when she performs them at which rate?

Accepted Answer

The 2010 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute.

Question 9

The nurse is providing an educational seminar to a group of nursing students on the advantages of using an automated external defibrillator (AED).She knows that her teaching has been effective when the students reply:

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 need for 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 10

The nurse enters her patient's room to find him unresponsive.She begins cardiopulmonary resuscitation (CPR)according to protocol.How deep should the nurse do chest compressions in this pulseless adult?

Accepted Answer

Chest compressions for an adult are done on the lower half of the sternum between the
aipples, with the heel of one hand and with the other hand on top compressing 11ec60b0_af3f_899c_b474_7f2573c02674_TB34225555_11 to 2
inches. One halfto 1 inch or 1 to 11ec60b0_af40_73fd_b474_cd078000317f_TB34225555_11 inches is no longer recommended. For children and
infants, the recommendation is 11ec60b0_af40_e92e_b474_a12bba2c7070_TB34225555_11  the depth of the chest. 11ec60b0_af41_856f_b474_b71e1ea2d07d_TB34225555_11 to 3 inches is too deep
for the average adult.

Question 11

Which of the following is the appropriate technique for a nurse to implement when inserting an oral airway?

Accepted Answer

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

Question 12

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 13

The nurse observes a person collapse and stop breathing.The nurse would establish an airway by:

Accepted Answer

The nurse would establish an airway by tilting the head back and lifting the chin.An endotracheal tube should not be inserted by the nurse.It is not necessary to put tension on the tongue because proper head tilt with chin thrust will remove the tongue from obstructing the airway.A modified jaw thrust would be used if a neck injury was suspected,but because this patient collapsed in front of the nurse,that would not be a concern in this scenario.

Question 14

When using an automated external defibrillator,it is important for the nurse to ensure that no one is touching the patient:

Accepted Answer

The nurse needs to ensure that no one is touching the patient while the machine is analyzing because this may interfere with correct interpretation of the patient's rhythm and could put anyone touching the patient at risk of being shocked.Cardiopulmonary resuscitation (CPR)may be continued up until the machine is ready to analyze,although CPR may need to be momentarily stopped for placement of the chest pad,and when the AED instructs the user to resume CPR.There is no risk in touching the patient while the machine is plugged in,and it is not possible to apply the pads without touching the patient.CPR should be performed until an automated external defibrillator (AED)is brought to the patient and the cable is ready to be inserted into the machine with the pads already in place.

Question 15

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

Accepted Answer

Give two breaths using mouth-to-mouth with a barrier device or a mouth-to-mask device or a 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.

Question 16

When applying an automated external defibrillator,the nurse would:

Accepted Answer

As soon as the cable is connected,the machine begins to attempt to analyze the rhythm,so the power should be turned on and the pads should be applied to the chest wall before the cable is connected to the machine.Connecting the cable,applying the pads,and then turning on the power would cause the machine to malfunction or would delay analysis while it cycles on.Connecting the cable before applying the pads could result in the rescuer being shocked.

Question 17

The nurse is performing cardiac compressions on a 4-year-old child with the assistance of another nurse.The nurses would deliver breaths and compressions at a ratio of _____ compressions for _____ breaths.

Accepted Answer

The correct ratio of compressions to breaths is 15 chest compressions followed by 2 breaths if there are two rescuers for a child.A ratio of 30:2 would be used in adult CPR;if there are two rescuers,1 breath is interspersed after 15 compressions but the ratio remains 30:2.Ratios of 5:1 and 5:2 are always incorrect when CPR is performed on a child.

Question 18

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

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.If respirations are absent,assist the code team with endotracheal intubation.Have available a laryngoscope handle,curved and straight blades,endotracheal (ET)tubes,a stylet,suction and tape,or an ET tube holder.

Question 19

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 cm.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 on the basis of the patient's age and the width and length of the patient's mouth.

Question 20

For which of the following patients would the nurse request the rapid response team's immediate intervention?

Accepted Answer

The nurse would request the rapid response team's immediate intervention for the patient with chest pain,hypotension,and shortness of breath to prevent a potentially life-threatening situation.A patient with postoperative pain can be successfully treated by the nurse on the unit and does not require the rapid response team.If the patient has no pulse and no respirations,the nurse should call the arrest team,not the rapid response team.The nurse should call the primary care provider for the patient who is hypertensive.

Quiz 28: Emergency Measure for Life Support