18 minute read
Chapter 30: Emergency Measures for Life Support
from TEST BANK FOR NURSING INTERVENTIONS & CLINICAL SKILLS, 7TH EDITION BY PERRY, POTTER. Test Bank with
by ACADEMIAMILL
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 OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Initiate cardiac compressions. b. Call for a code from the room. c. Help the patient back into the bed. d. Verify patient unresponsiveness.
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?
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 OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Deliver chest compressions. b. Help with patient positioning as directed. c. Inform the family about the patient. d. Prepare emergency medications.
3. The nurse determines that the patient is in cardiac arrest. Which does the nurse delegate to nursing assistive personnel (NAP)?
ANS: B
The nurse instructs the NAP to help position the patient, including logrolling onto a backboard or other positions for resuscitative measures, because the NAP receives training to perform the task. Agency policy usually dictates nursing responsibilities during a code. Although NAP are trained to perform basic cardiopulmonary resuscitation (CPR) and use the automatic external defibrillator (AED), the nurse is present; thus the nurse delivers chest compressions. The nurse does not delegate family communication to the NAP because the nurse has the critical thinking skills and clinical judgment to discuss the patient with the family and provide meaningful information and this is within the scope of nursing practice. The nurse retains responsibility for medications during a code because he or she receives training to administer emergency medications properly.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Bruising is present over the anterior thorax. b. The abdomen has become distended. c. The patient has an advance directive. d. An airway is in place without gagging.
4. The nurse participates in the patient’s resuscitation. Which patient assessment finding does the nurse determine to be an undesirable event during cardiopulmonary resuscitation (CPR)?
ANS: B
Abdominal distention is undesirable during CPR because it is consistent with clinical indicators of air in the stomach, which can potentially occur from esophageal intubation with the endotracheal tube or ventilating the patient with an Ambu bag and airway. Because distention increases the risk of patient aspiration or expiration, the resuscitation team investigates the distention, verifies endotracheal tube placement, and inserts a nasogastric tube for decompression. Thoracic bruising from chest compressions is usually unavoidable; however, since the bruises can upset the family, the nurse should discuss them with the family to ensure understanding. The health care team welcomes the patient’s advance directive to clarify resuscitative measures promptly. Maintaining an airway without patient gagging is a desirable event during the code because it facilitates patient oxygenation and ventilation. However, although this allows for breathing, the code team would rather discontinue the airway with spontaneous patient respirations and airway maintenance.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation a. Places the AED next to the patient, turns on the unit, and follows the prompts. b. Receives training in advanced cardiac life support (ACLS). c. Applies a shock in coordination with the chest compressions. d. Uses the automatic defibrillator instead of conventional cardiopulmonary resuscitation (CPR).
5. The patient is in cardiac arrest, and the nurse uses the automatic external defibrillator (AED). Which does the nurse implement to use the AED?
ANS: A
The nurse places the AED next to the patient near the chest or head and then turns on the unit. The unit has verbal prompts. The AED is user friendly with clear instructions labeled on the gel pads and instructions embedded on the AED unit. An AED user needs to follow directions correctly to use an AED effectively. ACLS training is unnecessary to use an AED. The nurse avoids delivering shocks and chest compressions together to prevent accidental electrocution. An AED is used along with conventional CPR because the AED does not compress the chest; its only function is analyzing the patient’s electrocardiogr am (ECG) and delivering defibrillations.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Request the chaplain speak to the family. b. Begin performing post-mortem cares. c. Provide privacy but stay available to the family. d. Gather funeral home information.
6. The patient’s resuscitation lasts 30 minutes. The code team leader has directed the efforts to stop. What action by the nurse is the priority?
ANS: C
The priority for the nurse after a patient’s death is to use his or her authentic presence as an intervention. The nurse provides the family privacy and remains available to answer questions and to provide support. A chaplain may or may not be welcomed by the family; the nurse would offer this option. Post mortem cares are done but the priority for the nurse is supporting the family; this care can be delegated to NAP. The nurse will need funeral home information but this can wait until the family is more settled.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Integrated Process: Caring a. Puts both hands over the upper half of the child’s sternum. b. Places the heel of one hand on the lower half of the sternum. c. Puts the heels of both hands on the lower third of the sternum. d. Places two fingers below the left nipple line at the sternum.
7. The nurse has just called a code and is preparing to perform cardiopulmonary resuscitation (CPR) on a child. Where does the nurse position the hands for chest compressions?
ANS: B
The nurse uses the heel of one (or two) hand(s) and on the lower half of the sternum to deliver chest compressions to a child to avoid traumatizing the distal sternal edge. Compressing the chest on the upper half or the lower third of the sternum risks trauma to the patient. Two fingers cannot deliver enough pressure to deliver effective chest compressions to a child.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Radial b. Carotid c. Brachial d. Temporal
8. The nurse has been performing cardiopulmonary resuscitation (CPR) on an adult. Which artery does the nurse check to evaluate the effectiveness of chest compressions?
ANS: B
The nurse evaluates the effectiveness of chest compressions during CPR by palpating a carotid pulse because it is a large artery close to the heart. He or she uses an artery proximal to the heart because the chest compressions are unlikely to perfuse the p atient’s periphery. The nurse avoids using the radial and brachial arteries because they are distal to the heart. The temporal artery is too small to provide an evaluation of the effectiveness of CPR.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. 5:1 b. 5:2 c. 10:1 d. 30:2
9. The nurse and a colleague begin cardiopulmonary resuscitation (CPR) on an adult patient. Which ratio of chest compressions to rescue breaths is used?
ANS: D
The latest guidelines issued by the American Heart Association recommend a ratio of chest compressions to rescue breaths of 30:2 to balance the need to circulate blood and oxygenate the adult patient. The remaining options are not suitable for two-person CPR.
N
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Have another nurse check the carotid pulse. b. Activate the emergency response system. c. Perform a jaw thrust to open the airway. d. Begin performing CPR.
10. On entering a patient’s room, the nurse determines that the patient is unresponsive but has a pulse and is breathing. Which action does the nurse implement next?
ANS: D
Since this patient has a pulse and respirations, but is unresponsive, the nurse calls the emergency response team to determine the next steps in care. The nurse should be able to assess a pulse without needing a second chance, and if the person is breathing, a pulse should be present. If the person is breathing adequately, the airway is patent. There is no reason to start CPR on a person with a pulse who is breathing.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. One half to 1 inch in depth b. One to 1 1/2 inches in depth c. One half the depth of the chest d. One third the depth of the chest
11. The nurse needs to perform chest compressions for a pulseless child. Which depth does the nurse use for each chest compression?
ANS: D
The nurse performs chest compressions on a child by compressing the chest by at least one third the depth of the child’s chest, or about 2”. This effectively displaces blood from the heart without traumatizing regional tissue.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Head tilt and right side-lying position b. Logrolling and jaw thrust c. Supine and head tilt d. Jaw thrust and semi-Fowler’s position
12. The nurse determines that the patient had a cardiac arrest while ambulating in the hall. Which method should the nurse use to position the patient properly during cardiopulmonary resuscitation (CPR)?
ANS: B
The nurse uses logrolling to position the patient onto a hard surface for chest compressions because emergency care must be implemented as though the patient has an unstable spine. Logrolling maintains spine alignment until injury to the spine is ruled out. The nurse uses the jaw thrust to open the airway of a patient with a suspected unstable spine and determines whether the patient has spontaneous respirations without hyperextending the neck. The patient collapsed in the hallway and potentially suffered head or neck trauma; thus, until the status of the spine is determined, the nurse treats the patient as though the spine is unstable. Side-lying position during CPR is contraindicated because it is impossible to deliver effective chest compressions unless the patient is supine on a hard, flat surface. Supine positioning also facilitates blood flow to the brain to minimize cerebral hypoxia.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Provide 5 cycles of cardiopulmonary resuscitation (CPR) before shocking. b. Place AED pads and shock as soon as possible, if needed. c. Insert an oropharyngeal airway before shocking. d. Place the AED pads on either side of the chest.
13. A visitor has coded in the hospital cafeteria, and several nurses witnessed the code. What is the proper procedure for initiating use of the automatic external defibrillator (AED)?
ANS: B
Once an AED is available the nurse turns it on, applies it, and lets it analyze the patient’s rhythm. The AED will deliver a shock if the rhythm is appropriate for it. The pads do go on either side of the chest but have specific placement. An oropharyngeal airway is not needed prior to shocking.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Provide 2 minutes of cardiopulmonary resuscitation (CPR) before beginning rhythm analysis and the shock sequence again. b. Provide three cycles of CPR before beginning rhythm analysis and the shock sequence again. c. Move nearby furniture away from the patient. d. Announce “clear” and perform a visual check that no one is touching the patient.
14. An AED has been applied and a shock delivered to a patient. What action does the nurse take at this time?
ANS: A
Two minutes of CPR are to be performed before beginning the rhythm analysis and the shock sequence again. Most newer AEDs will direct responders to not touch the patient for rhythm analysis instead of needing to rely on someone keeping time. Delegate someone to remove excess furniture or equipment from the immediate area. Directing personnel to stand clear of the patient should be done before the shock is performed, not after. The patient needs ongoing assessment by the nurse.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. For children younger than 8 years old, pediatric AED pads should be used. b. The AED takes approximately 30 seconds to analyze the cardiac rhythm. c. The AED is used when the patient is unconscious and has no respirations. d. The AED is placed near the patient’s feet during use.
15. A nurse is instructing staff nurses in the use of the automatic external defibrillator (AED). Which information is essential for the nurse to share with the class?
ANS: A
AED pads designed for children should be used for children younger than 8 years of age. If child pads are not available, use adult pads. The AED takes approximately 5–15 seconds to analyze the cardiac rhythm. It is used when the patient has no pulse, and is placed near the patient’s chest or head.
N
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Ask the student if he or she is too tired to continue. b. Assess for a pulse at the femoral or carotid artery. c. Remind the student to switch to ventilations after 2 minutes. d. Tell the student he or she needs faster compressions.
16. A student nurse is performing compressions on an adult. The rate of compressions drops to 90/min. What action by the faculty member is best?
ANS: D
The compression rate for an adult is 100–120/min. A rate of 90 is too slow and not effective. The faculty would remind the student to switch places after 2 minutes or ask if the student is too tired to continue, but the priority is effective CPR. Pulses would be checked at the femoral artery preferably, because the carotid artery is difficult to access during a code.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Performs compressions with two fingers at the nipple line. b. Compresses at a rate of at least 130/min. c. Gives breaths to the intubated child every 6 seconds. d. Continues 30:2 ratio with two rescuers.
17. A student nurse is performing CPR on a child manikin. What action does the faculty member evaluate as effective technique?
ANS: C
Once the patient has an advanced airway, compressions are no longer interrupted for ventilations which are then delivered every 6 seconds, or about 10 times per minute. Using two fingers just below the nipple line is appropriate for infant CPR. The compression rate for children is 100
120/min. Two rescuer child CPR uses a 15:2 ration of compressions to breaths.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation a. Unwitnessed cardiac arrest, initial rhythm asystole b. Witnessed cardiac arrest, rapid defibrillation with AED c. Witnessed cardiac arrest, alert but amnesic for event d. Unwitnessed cardiac arrest with multiple medical problems
18. The coronary care unit is receiving four patients in the next hour. Which patient does the charge nurse anticipate will receive targeted temperature management?
ANS: B
The best outcomes are seen in patients who had a cardiac arrest with an initial rhythm that was shockable. In this patient, not only was the rhythm shockable, but defibrillation was provided rapidly. Asystole is not a shockable rhythm. An alert patient would not be a candidate for targeted temperature management. Not enough is known about the patient with multiple medical problems to suggest targeted temperature management.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. It improves neurological outcomes after cardiac arrest. b. It manages the fever produced by defibrillation. c. It salvages the damaged heart muscles. d. It keeps the fluid and electrolytes in balance.
19. A patient is receiving targeted temperature management after cardiac arrest. What explanation of this treatment does the nurse provide the family?
ANS: A
The purpose of targeted temperature management is to reduce neurological deficits after cardiac arrest. It is not used for fever control, salvaging damaged heart muscle, or maintaining fluid and electrolyte balance.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Integrated Process: Teaching-Learning a. Patient is awake, alert, and oriented. b. Patient’s temperature is 35° C (95° F). c. Only the patient’s sodium level is abnormal. d. The patient’s oxygen saturation is 88%.
20. The nurse is caring for a patient receiving targeted temperature management. It has been 20 hours since the therapy was initiated. What assessment finding indicates goals are being met?
ANS: B
The target is a temperature of 32–36° C (89.6-96.8° F) for 24 hours. This patient’s temperature is in the target range, indicating goals for the therapy are being met. The patient will not be awake, alert, and oriented; if he or she were, this therapy would not be needed. Electrolytes are maintained in normal ranges. Oxygen saturation is maintained at greater than 90% or above.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation a. Remove the oral airway. b. Consult the provider. c. Replace the airway after 24 hours. d. Document ongoing need.
21. The nurse is caring for a post-cardiac arrest patient who has needed an oral airway for 20 hours. What action by the nurse is most appropriate?
ANS: B
An oral airway is a temporary solution to maintaining a patient’s airway and can cause tissue damage. The nurse will consult the provider about a more appropriate long-term management strategy. The nurse would not simply remove the airway if it is still needed, nor is replacing it every 24 hours required. The nurse documents the treatment and the patient’s response.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
22. A new pediatric nurse is asking the charge nurse why an oral airway is not rotated while being inserted in pediatric patients. What response by the charge nurse is best?
N a. The airways are so small, you will not be able to hold on to it. b. Oral pharyngeal airways actually are not used in pediatric patients. c. Rotating the airway can possibly further obstruct the child’s airway. d. You risk damaging the child’s soft palate by rotating the airway.
ANS: D
Rotating a pediatric oral airway while inserting it will damage the delicate soft palate of the child. There is no other reason why it is not done.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
Multiple Response
1. The nurse is assessing an unconscious patient for placement of an oropharyngeal airway. In addition to a present gag reflex, what other conditions would make the use of the airway contraindicated? (Select all that apply.)
a. A semi-conscious patient b. A patient with a loose tooth c. A patient who had facial trauma d. A patient who has had oral surgery e. A patient with copious secretions
ANS: A, B, C, D
An oropharyngeal airway should never be inserted in a patient with recent oral trauma, oral surgery, or loose teeth. A semi-conscious patient may vomit or have spasms of the larynx if an airway is inserted.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Place the patient in a prone position. b. Hold the airway curved end up initially. c. Use a padded tongue blade to open patient’s mouth. d. Measure the airway to obtain the right size. e. Rotate the airway 90 degrees as it is inserted.
2. The nurse in a trauma center is preparing to insert an oropharyngeal airway device. Which interventions will assist in this task? (Select all that apply.)
ANS: B, C, D, E
The nurse will place the patient in a supine or semi-Fowler’s position. Hold the oral airway with the curved end up and insert the distal end until the airway reaches the back of the throat; then turn the airway over 180 degrees and follow the natural curve of the tongue. Option: Hold the airway sideways and insert halfway; rotate the airway 90 degrees while gliding it over the natural curvature of the tongue. Make sure the outer flange is just outside the patient’s lips. The airway must be measured to ensure the right size.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. End-tidal CO2 should be above 20, if available. b. A size 1 or 2 oral airway fits most adults. c. Compressions on an adult should be at least 100/min. d. Adult-sized AED pads cannot be used on children. e. Adult CPR uses 30 compressions followed by 2 breaths.
3. A student nurse is reviewing CPR guidelines with the faculty. What statements by the student indicate the need for a review? (Select all that apply.)
ANS: B, D
If available, end-tidal CO2 is kept above 20 mm to indicate adequate respirations. Compressions on an adult are 100–120/min in a sequence of 30 compressions followed by 2 breaths. A size 1 or 2 oral airway fits children aged 1–6. Pediatric AED pads are preferable for children, but if they are not available, adult pads can be used.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Uses the 2-thumb encircling method with 2 rescuers. b. Provides compressions at a rate of 140/min. c. Inserts an appropriately sized oral airway. d. Attaches the AED as soon as it’s available. e. Compresses the chest approximately 1".
4. The charge nurse is assessing staff CPR skills. What actions by the staff are appropriate for infant CPR? (Select all that apply.)
ANS: A, C, E
For infant CPR the two-thumb encircling method for compressions is used when there are 2 rescuers, who compress the chest approximately 1" at 100–120 times per minute. A size 0-00 oral airway is appropriate for infants. Manual defibrillation is used on infants.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Dries wet skin before applying AED pads. b. Uses pediatric pads on an adult if bigger ones aren’t available. c. Places pads on the back if the chest is wet. d. Attaches the pads then turns the device on. e. Modifies pad position for pacemakers.
5. A student nurse is practicing using the AED. What actions by the student show the need for remediation? (Select all that apply.)
ANS: B, C, D
The student needs remediation on these steps because pediatric pads will not be effective on an adult; he or she should dry the patient’s chest off and apply pads to the chest, not the back; and turns the device on first. The student is correct in drying wet skin prior to applying pads and modifying pad placement for pacemakers.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
Matching
Match the unexpected response with the appropriate action.
a. Consult with provider for appropriate diagnostic testing.
b. Ensure AED pads have appropriate contact on the skin.
c. Remove the oral airway.
d. Consult provider for definitive therapy.
e. Assess rate and depth of ventilations.
1. Unable to insert oral airway.
2. Burns are visible under AED pads.
3. Resuscitated patient reports abdominal pain.
4. Oxygen saturation decreased after inserting oral airway.
5. Patient’s abdomen visibly distended during CPR.
1. ANS: D DIF: Cognitive Level: Applying
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
MSC: If the patient needs an airway and the nurse is unable to insert an oral airway, the nurse will consult the provider about more advanced methods of controlling the airway.
2. ANS: B DIF: Cognitive Level: Applying
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
MSC: If burns are occurring the nurse will assess that the patient's skin is dry and that the pads have good contact. If more pads are available, the nurse would change pads to a different position if possible.
3. ANS: A DIF: Cognitive Level: Applying
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
MSC: Injuries to bones and internal organs are possible during CPR, so the nurse consults with the provider about obtaining appropriate diagnostic testing.
4. ANS: C DIF: Cognitive Level: Applying
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
MSC: If insertion of an oral airway causes the patient's condition to deteriorate, the nurse removes the oral airway and reassesses the situation.
5. ANS: E DIF: Cognitive Level: Applying
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
MSC: Ventilations that are too deep or too rapid can cause gastric insufflation, potentially leading to vomiting and aspiration. The nurse checks to ensure ventilations are appropriate.
