TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 30: Emergency Measures for Life Support Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for four patients on the intermediate care unit and plans emergency care
for the patients. Which patient is unsuitable for cardiopulmonary resuscitation (CPR)? a. The older adult patient with end-stage lung disease b. The patient with a valid order for a no-code status c. The patient who doesn’t speak English and cannot make his or her wishes known d. The patient whose family does not want the patient resuscitated ANS: B
The patient who has a valid order to withhold patient resuscitation from the health care provider or according to agency policy should not receive CPR if breathing stops, the heart stops beating, or the patient cannot maintain an airway. The nurse communicates the patient’s directive to withhold resuscitative measures to the entire nursing staff because inadvertent CPR can result in legal liability. Unless the patient specifies that CPR is to be withheld, the nurse must institute resuscitative measures as the need arises despite a grim diagnosis or advanced age. A patient who cannot speak English needs to have an interpreter to provide information on emergency options and assist the patient to complete advance directives. This is a priority for non-English speaking persons. Unless the patient is incompetent, the family cannot decide his or her code status because it violates the patient’s right to self-determination and to refuse treatment. DIF: Cognitive Level: Understanding N TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
2. The nurse walks into a patient’s room and finds the patient on the floor with eyes closed.
Which does the nurse implement first? a. Initiate cardiac compressions. b. Call for a code from the room. c. Help the patient back into the bed. d. Verify patient unresponsiveness. ANS: D
The nurse assesses the patient for unresponsiveness by touching him or her and calling, “Are you okay?” before activating a code. Although unresponsiveness can be caused by many factors, the nurse wants to stimulate the patient and improve breathing first if possible. The nurse avoids initiating chest compressions until assessing for a pulse because chest compressions over a beating heart can precipitate arrhythmias. Until the patient’s status is assessed, a code should not be activated. The nurse should not move the patient alone; if CPR is needed, the hard floor is a suitable surface until enough help arrives to put the patient back into bed. The nurse is not aware of why the patient is on the floor; thus the team members must consider the possibility of a spinal cord injury; however providing CPR and resuscitation is the priority. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
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