NCLEX questions-Cardiopulmanary Resuscitation

The nurse witnesses the collapse of a victim in her neighborhood and suspects cardiac arrest. Which action should the nurse take first? 1. Initiate rescue breathing 2. Begin giving chest compressions 3. Activate the emergency response system 4. Obtain an automated external defribillator

3. Rationale-If a collapse is witnessed and the nurse suspects cardiac arrest, the nurse should first activate the emergency response system. Next, the nurse should obtain an automated external defibrillator, followed by initiation of cardiopulmonary resuscitation, beginning with chest compressions.

The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider (HCP)? 1. One breath should be given for every five compressions 2. Two breaths should be given for every 15 compressions 3. Initially, two quick breaths should be given as rapidly as possible 4. Each rescue breath should be given over 1 second and should produce a visible chest rise

4. Rationale-In adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. HCP's should employ a 30:2 compression-to-ventilation ratio for the adult victim.

The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method? 1. Flexed position 2. Head tilt-chin lift 3. Jaw thrust maneuver 4. Modified head tilt-chin lift

3. Rationale-If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. the head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an an inappropriate position for opening the airway.

The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions the nurse compressses at least how many times? 1. 60 times per minute 2. 80 times per minute 3. 100 times per minute 4. 160 times per minute

3. Rationale-In an infant, the rate of chest compressions is at least 100 times per minute.

The nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action? 1. Open the airway 2. Give the client oxygen 3. Start chest compressions 4. Ventilate with a mouth-to-mask device

3. Rationale-The next nursing action would be to start chest compression. Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim's airway.

The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)? 1. 3/4 inch 2. 1 inch 3. 2 inches 4. 3 inches

3. Rationale-When performing CPR on an adult client, the sternum is depressed 2 inches. The depth for the adult and the child is 2 inches whereas for the infant is 1 1/2 inches.

The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands this reason if the student makes which statement? 1. "The object may have been swallowed." 2. "The infant may bite down on the finger." 3. "The mouth is too small eo see the object." 4. "The object may be forced back farther into the throat."

4. Rationale-Blind finger sweeps are nit recommended for infants and children because of the risk of forcing the object farther down into the airway. The other options do not identify reasons for avoiding blind finger sweeps.

The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child? 1. 6-8 2.8-10 3. 10-12 4. 12-14

1. Rationale-In a child between the ages of 1 and 8 years, one breath every 6-8 seconds is delivered.

The nursing instructor asks a nursing student to describe the procedure for performing abdominal thrusts on an unconscious pregnant woman at 32 weeks' gestation. The student describes a component of the procedure correctly if the student states that he will take which action. 1. Place his hands on the pelvis to perform the thrusts 2. Perform abdominal thrusts until the object is dislodged 3. Perform left lateral abdominal thrusts until the object is dislodged 4. Place a rolled blanket under the right abdominal flank and hip area

4. Rationale-If an unconscious woman in an advanced gestational stage of pregnancy has a foreign body airway obstruction, the woman is placed on her back. A wedge, such as a pillow or rolled blanket , is placed under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. This prevents supine hypotension that can occur if the gravid uterus rests on the vena cava. The rescuer then attempts ventilations; if ventilation is unsuccessful, the rescuer positions the hands as for chest compressions and delivers firm chest thrusts to remove the obstruction. Placing the hands on the pelvis or abdomen and performing left lateral abdominal thrusts are ineffective and could be harmful.

The nurse attempts to relieve an airway obstruction in a 3-year-old conscious child. The nurse performs the abdominal thrust maneuver correctly by standing behind the child, placing her arms under the child's axillae and around the child, and positioning her hands to deliver the thrusts between which areas? 1. Groin and the abdomen 2. Umbilicus and the groin 3. Lower abdomen and the chest 4. Umbilicus and the xiphoid process

4. Rationale-To perform abdominal thrusts on a child, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The rescuer places the thumb side of one fist against the victim's abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrusts. One must take care not to touch the xiphoid process or the lower margins of the rib cage because force applied to these structures may damage internal organs.