Chapter 27: Emergency Measures for Life Support Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is providing 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?

a.

60 to 80 per minute

b.

120 per minute

c.

100 per minute

d.

40 to 60 per minute

ANS: C

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

DIF: Cognitive Level: Application REF: Text reference: p. 685

OBJ: Discuss code management. TOP: Chest Compressions

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. 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?

a.

Size 1

b.

Size 2

c.

Size 3

d.

Size 7

ANS: C

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 on the basis of the patients age and the width and length of the patients mouth.

DIF: Cognitive Level: Application REF: Text reference: p. 678

OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR).

TOP: Oral Airway KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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 patients cheek. Where is the end of the curve?

a.

At the angle of the jaw

b.

Above the ear

c.

To the level of the nose

d.

Upside down

ANS: A

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

DIF: Cognitive Level: Application REF: Text reference: p. 677

OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR).

TOP: Oral Airway KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

Ability of the patient to speak

b.

Ability of the patient to cough forcefully

c.

Presence of wheezing between coughs

d.

Presence of gurgling with the respiratory cycle

ANS: D

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.

DIF: Cognitive Level: Application REF: Text reference: p. 678

OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR).

TOP: Oral Airway KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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:

a.

with oral trauma.

b.

with loose teeth.

c.

who are unconscious.

d.

who have had recent oral surgery.

ANS: C

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.

DIF: Cognitive Level: Application REF: Text reference: p. 678

OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR).

TOP: Oral Airway KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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

a.

Insert the airway with the curved end up, then rotate it 180 degrees at the back of the throat.

b.

Insert the airway with the curved end down along the curve of the tongue.

c.

Use a tongue blade to insert and push the airway into position.

d.

Insert the airway sideways, then rotate it with the curved end up.

ANS: A

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).

DIF: Cognitive Level: Application REF: Text reference: p. 679

OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR).

TOP: Oral Airway Insertion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. 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:

a.

Health care providers do not need to learn CPR to use the AED.

b.

The health care provider is given a printout of the rhythm change.

c.

The health care provider can safely use both CPR skills and AED skills.

d.

The health care provider can adjust the level of shock administered.

ANS: C

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.

DIF: Cognitive Level: Application REF: Text reference: p. 680

OBJ: Identify the need for automated external defibrillator (AED) application and indications for use. TOP: Advantages of an Automated External Defibrillator (AED)

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. 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 nurses first action?

a.

Give two breaths using mouth-to-mouth without a barrier device.

b.

Give two breaths using mouth-to-mouth without a barrier device and watch for chest movement.

c.

Give two breaths using a bag-mask device.

d.

Start chest compressions until an AED is available.

ANS: C

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.

DIF: Cognitive Level: Application REF: Text reference: p. 687

OBJ: State the end points for CPR. TOP: Mouth-to-Mouth With a Barrier Device

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. 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?

a.

Open the airway using the head tiltchin lift method.

b.

Open the airway using the jaw-thrust method.

c.

Give two breaths using mouth-to-mouth and a barrier device.

d.

Give two breaths using a bag-mask device.

ANS: B

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.

DIF: Cognitive Level: Analysis REF: Text reference: p. 685

OBJ: State the end points for CPR. TOP: Jaw-Thrust Maneuver

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. 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?

a.

Immediately intubate the patient.

b.

Have a laryngoscope handle and curved blades available.

c.

Ensure that the light source on the laryngoscope is functional.

d.

Have a laryngoscope handle and straight blades available.

ANS: C

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.

DIF: Cognitive Level: Application REF: Text reference: p. 690

OBJ: Discuss code management. TOP: Intubation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

8 per minute

b.

12 per minute

c.

20 per minute

d.

24 per minute

ANS: A

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

DIF: Cognitive Level: Application REF: Text reference: p. 685

OBJ: Discuss code management. TOP: Rescue Breathing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. The nurse enters her patients room to find him unresponsive. She begins CPR according to protocol. How deep should the nurse do chest compressions in this pulseless adult?

a.

1 to inches in depth

b.

to 3 inches in depth

c.

to 1 inch in depth

d.

to 2 inches in depth

ANS: D

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 to 2 inches. One half to 1 inch or 1 to inches is no longer recommended. For children and infants, the recommendation is to the depth of the chest. to 3 inches is too deep for the average adult.

DIF: Cognitive Level: Application REF: Text reference: p. 685

OBJ: Discuss code management. TOP: Chest Compressions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

inserting an endotracheal tube.

b.

inserting a finger to pull the tongue forward.

c.

using the head tiltchin lift maneuver.

d.

using a modified jaw-thrust maneuver.

ANS: C

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.

DIF: Cognitive Level: Application REF: Text reference: p. 687

OBJ: State the end points for CPR. TOP: Steps Used in Performing Rescue Breathing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. 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.

a.

30; 2

b.

5; 1

c.

15; 2

d.

5; 2

ANS: C

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.

DIF: Cognitive Level: Application REF: Text reference: p. 685

OBJ: State the end points for CPR.

TOP: Steps Used in Administering External Cardiac Compressions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. When applying an automated external defibrillator, the nurse would:

a.

connect the cable to the machine, apply the pads, and turn on the power.

b.

turn on the power, apply the pads, and connect the cable.

c.

turn on the power, connect the cable, and apply the pads.

d.

connect the cable, turn on the power, and apply the pads.

ANS: B

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.

DIF: Cognitive Level: Application REF: Text reference: p. 681

OBJ: State the end points for CPR.

TOP: Steps Used in Administering Automated External Defibrillation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

after connecting the cable to the machine.

b.

when the machine is plugged in.

c.

while the pads are applied.

d.

while the machine analyzes the rhythm.

ANS: A

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 patients rhythm and could put anyone touching the patient at risk of being shocked. 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 AED is brought to the patient and the cable is ready to be inserted into the machine with the pads already in place.

DIF: Cognitive Level: Application REF: Text reference: p. 682

OBJ: State the end points for CPR.

TOP: Steps Used in Administering Automated External Defibrillation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

CPR.

b.

defibrillation.

c.

oxygen.

d.

precordial thump.

ANS: B

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.

DIF: Cognitive Level: Application REF: Text reference: p. 676 |Text reference: p. 680

OBJ: State the end points for CPR.

TOP: Key Terms Used in the Skills of Hospital Emergency Measures and Cardiopulmonary Resuscitation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

a.

A patient with blood pressure of 60/28

b.

A patient experiencing severe dyspnea secondary to asthma

c.

A patient in atrial fibrillation

d.

An unconscious patient in ventricular tachycardia

ANS: B

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.

DIF: Cognitive Level: Application REF: Text reference: p. 684

OBJ: Identify indications for requesting a rapid response or cardiac/respiratory arrest team.

TOP: Oral Airway KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

19. The nurse enters the patients 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 nurses most immediate action be?

a.

Call the cardiac/respiratory arrest team.

b.

Begin CPR.

c.

Call a co-worker for help.

d.

Get the crash cart.

ANS: A

The nurses first action should be to summon the cardiac/respiratory arrest team because it will take them a few minutes to arrive, and the patients best outcome depends on their rapid arrival. As soon as the team has been called, the nurse should begin 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.

DIF: Cognitive Level: Application REF: Text reference: p. 681

OBJ: Describe the role of the nurse in initiating and participating in a cardiopulmonary arrest situation in a hospital. TOP: Oral Airway

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20. For which of the following patients would the nurse request the rapid response teams immediate intervention?

a.

A patient complaining of severe postoperative incisional pain

b.

A patient with no pulse who is not breathing

c.

A patient complaining of chest pain, hypotension, and shortness of breath

d.

A patient with blood pressure of 164/96

ANS: C

The nurse would request the rapid response teams 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.

DIF: Cognitive Level: Application REF: Text reference: p. 676

OBJ: Identify indications for requesting a rapid response or cardiac/respiratory arrest team.

TOP: Oral Airway KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

21. A patient has been found with no pulse or respirations. The cardiopulmonary arrest team has been called. What should the nurse do while awaiting the teams arrival?

a.

Gather the patients medical record and medication administration record.

b.

Obtain the crash cart.

c.

Notify the patients primary care provider.

d.

Perform CPR.

ANS: D

The nurses responsibility while awaiting the arrest team is to perform CPR, with or without assistance as available. Other team members can collect the patients records, obtain the crash cart, and notify the primary care provider. The nurse assigned to the patient should stay with the patient to provide the history when the team arrives.

DIF: Cognitive Level: Application REF: Text reference: p. 685

OBJ: State the end points for CPR.

TOP: The Nurses Role in Initiating and Participating in a Cardiopulmonary Arrest Situation in a Hospital KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse in the ICU is caring for a newly admitted patient with chest pain. She is aware that dysrhythmia may be caused by which of the following? (Select all that apply.)

a.

Electrolyte disturbances

b.

Heart damage

c.

Medications

d.

Respiratory arrest

ANS: A, B, C, D

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.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 676

OBJ: State indications for cardiopulmonary resuscitation (CPR).

TOP: Cardiac Arrest KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The nurse walks into her patients room to find him unresponsive. She begins CPR, knowing that during a code situation, chest compressions should be interrupted for which of the following situations? (Select all that apply.)

a.

Ventilation

b.

Pulse checks

c.

Intubation

d.

Defibrillation

ANS: A, B, C, D

The 2010 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.

DIF: Cognitive Level: Application REF: Text reference: p. 690

OBJ: Discuss code management. TOP: Chest Compressions

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. 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.)

a.

Cleanse the mouth frequently using lemon glycerin swabs.

b.

Replace or clean the oral airway.

c.

Suction the oral cavity frequently.

d.

Keep the airway in place for extended periods.

ANS: B, C

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.

DIF: Cognitive Level: Application REF: Text reference: p. 679

OBJ: Demonstrate the following in a laboratory or clinical situation: insertion of an oral airway, use of an AED, and performance of cardiopulmonary resuscitation (CPR).

TOP: Oral Airway Maintenance KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. What is the nurses responsibility for the patient after he has been intubated during a code event? (Select all that apply.)

a.

Ventilate using a bag-mask device at a rate of 22 breaths per minute.

b.

Auscultate the epigastric area.

c.

Auscultate both lungs.

d.

Call for a chest radiograph.

ANS: B, C

Assist in confirmation of endotracheal tube placement by auscultating the 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. A chest radiograph usually is obtained after the patient has been stabilized to confirm placement of the endotracheal tube and central venous catheters.

DIF: Cognitive Level: Application REF: Text reference: p. 690

OBJ: Discuss code management. TOP: Intubation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. Many cardiac arrests are caused by irregular heart rhythms known as ________________.

ANS:

dysrhythmias

Many cardiac arrests are caused by irregular heart rhythms known as dysrhythmias.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 676

OBJ: State indications for cardiopulmonary resuscitation (CPR).

TOP: Cardiac Arrest KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. In the event of cardiopulmonary arrest, all patients receive CPR unless otherwise indicated in the patients _________________.

ANS:

advance directive

Unless otherwise indicated within a patients advance directive or a do-not-resuscitate (DNR) physicians order, all patients receive CPR in the event of an arrest.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 677

OBJ: State indications for cardiopulmonary resuscitation (CPR).

TOP: Advance Directives KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. A semicircular, minimally flexible, curved piece of hard plastic that is inserted into the mouth so it extends from just outside the lips to the pharynx is known as an ____________.

ANS:

oral airway

An oral airway is a semicircular, minimally flexible, curved piece of hard plastic. When inserted, it extends from just outside the lips, over the tongue, and to the pharynx. Oral airways enable the nurse to suction through a central core or along the side of the airway and to maintain airway patency in the unconscious patient.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 677

OBJ: Discuss indications for oral airway insertion. TOP: Oral Airway

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. The most common cause of airway obstruction in an unresponsive patient is the __________.

ANS:

tongue

The tongue is the most common cause of blocked airway in an unresponsive patient.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 678 |Text reference: p. 687

OBJ: State the end points for CPR. TOP: Airway Obstruction

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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