Critical care

6-year-old conscious child. Which location is the correct placement of the hands to perform this maneuver?

Between the umbilicus and the xiphoid process

client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which?

Start chest compressions

8-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which landmarks to remove the foreign body?

The umbilicus and xiphoid process

identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation

Under the right clavicle and to the left of the precordium

Hypothermia

abnormally low body temperature

(CPR) on an infant. When performing chest compressions, which is the compression rate for an infant?

100 times per minute

infant unresponsive and without respiration or a pulse. The nurse plans to deliver chest compressions at a rate of at least which?

100 times per minute

(CPR) on an adult client. How far should the sternum be depressed in an adult client for effective chest compressions?

2 inches

After determining proper hand placement, the nurse begins delivering compressions by pushing down on the chest at which depth?

2 inches

signs/symptoms of fluid overload

4. Dry cough 5. Distended neck veins

victim of a major burn injury. Which are the names of the primary phases of burn care assessment? Select all that apply.

1. Acute 5. Resuscitative 6. Rehabilitative

give ear drops to a 2-year-old child. To administer the drops, the nurse should pull the pinna of the ear in which direction?

Downward and backward

potassium level is 6.3 mEq/L. Based on the laboratory result, which signs/symptoms should the nurse anticipate?

1. Anxiety 5. Electrocardiogram (ECG) changes

When this rhythm of atrial fibrillation is noted on a client's monitor, the nurse needs to check all

1. Check all telemetry leads. 2. Check blood pressure (BP) 4. Obtain stat electrocardiogram (ECG). 6. Assess client's level of consciousness (LOC)

suctioning an endotracheal tube (ET) for an intensive care unit client who is being mechanically ventilated. Five minutes after suctioning, which primary outcomes should tell the nurse that the suctioning has been successful?

1. Clear lung sounds 2. Increase in O2 saturation 4. Heart rate on monitor within normal limits

treatment for acetaminophen (Tylenol) overdose. The nurse reviews the child's record and expects to note that the child received which for the acetaminophen overdose?

Acetylcysteine

An automatic external defibrillator (AED) is available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm by doing which?

Applying the adhesive patch electrodes to the skin and moving away from the client

primary problems can occur when cardiac pacemakers malfunction?

1. Failure to sense 3. Failure to capture 4. Failure to pace or fire

A client who weighs 50 kg has arrived in the emergency department complaining of severe chest pain. The telemetry monitor shows an evolving anterior myocardial infarction (MI). The nurse anticipates that the health care provider will initially prescribe which treatments?

1. Oxygen 2 L, per nasal cannula 2. Chewable aspirin 324 mg, oral 3. Nitroglycerin 0.4 mg, sublingual 5. Morphine sulfate 4 mg intravenously

Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors?

1. Receiving assurance 2. Receiving information 3. Having support available 4. Remaining near the client

(CPR) on an adult. The nurse should deliver how many breaths per minute to the client?

10

received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?

A decrease in oozing from puncture sites and gums

administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way?

Subcutaneously in the upper arm

most appropriate location for assessing the pulse of an infant who is less than 1 year old?

brachial

CLABSI

central line associated blood stream infection

give a subcutaneous dose of heparin sodium

Give the injection using a 25- to 27-gauge, ⅝-inch needle

basic life support (BLS) for nursing students. Which statement made by a nursing student indicates a need for further teaching?

I will remember the algorithm airway, breathing, and compressions to guide my actions when providing BLS./ The American Heart Association set forth new guidelines for BLS for the health care provider. Among these changes is a new emphasis on the algorithm CAB—compressions, airway, breathing—

on an adult client. The nurse should place the hands in which position to begin chest compressions?

On the lower half of the sternum

complaints of substernal chest pain and is taken directly to a stretcher in the department. Which priority intervention should the nurse undertake

Obtain an electrocardiogram (ECG)

A comatose client received therapeutic hypothermia after a cardiac arrest. The nurse anticipates which primary complications associated with this treatment?

1. Infection 2. Bleeding 6. Metabolic and electrolyte disturbances

A 50-year-old client with a history of cardiac disease has been admitted to the intensive care unit (ICU) with a diagnosis of acute alcohol withdrawal. Which initial client data should the nurse expect to find?

1. Insomnia 3. Diaphoresis 4. Tachycardia 6. Increased serum total bilirubin

An adult client is admitted to the emergency department with acute extensive partial thickness burns to the lower extremities. The nurse anticipates the health care provider will initially prescribe which medications and route for pain control?

1. Morphine sulfate intravenously 4. Hydromorphone (Dilaudid) intravenously

receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?

Chills, itching, or rash

receiving calcium disodium edetate (EDTA) for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result?

Blood urea nitrogen

3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?

Call the poison control center.

relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation

Place a rolled blanket under the right abdominal flank and hip area

client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions?

2. Strict hand washing 4. Optimal catheter site selection 5. Strict sterile technique with maximal barrier precautions during placement