PNE 142 Chapter 37: Resuscitation

The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of new parents. The nurse asks a parent to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the parent understands this reason based on which statement?

"The object may be pushed back farther in the throat."

A nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? Select all that apply.

*compromised swallowing *aspiration of vomitus *insufficient chewing

A nurse must perform chest compressions. What is the correct rate?

100 per min

When performing CPR on an infant, the nurse who is alone would use which to perform chest compressions?

2 fingers

When performing chest compressions during CPR, the nurse compresses the chest of an adult to a depth of at least:

2 inches

A nurse has just become certified in basic life support. The nurse would expect to refresh these skills within which time frame?

2 years

A nurse is administering chest compressions to assist the circulation of an unconscious person. How many compressions should the nurse give?

30 compressions

31s Report this Question A nurse is performing the Heimlich maneuver on an infant and is holding the infant prone with the head downward. How many back slaps should the nurse administer?

5

A nurse is performing the Heimlich maneuver on an infant and is holding the infant prone with the head downward. How many back slaps should the nurse administer?

5

A person has experienced cardiac arrest. The nurse is initiating resuscitation after determining unresponsiveness and activating the emergency medical response system. Which action would the nurse do first?

Administer 30 chest compressions.

An 18-month-old client had a small toy in the mouth and is now drooling and appears distressed, but the client is not crying. Which intervention is the priority?

Administer five abdominal thrusts.

The nurse is caring for a 13-month-old client who is eating whole grapes and is suddenly unable to ventilate. The client is not able to cough or cry. What will the nurse do first?

Administer five quick subdiaphragmatic (abdominal) upward thrusts above the navel.

An unconscious adolescent is brought to the emergency department with a respiratory rate of 6 breaths/min following a suspected opioid drug overdose. What is the nurse's most appropriate action?

Administer naloxone.

Two nurses are walking back to their unit from the cafeteria. Suddenly, Nurse 1 stops walking and laughing, grabs her throat with both hands, and makes a high-pitched noise while inhaling. What would Nurse 2 do first?

Ask Nurse 1, "Are you choking?"

While jogging through the neighborhood, a nurse witnesses the collapse of a nearby jogger and suspects cardiac arrest. Which action should the nurse take first?

Assess the victim for consciousness.

A nurse working in a pediatric unit finds an infant unresponsive without respirations or a pulse. After calling for help, what is the nurse's most appropriate action?

Begin chest compressions.

A team of students nurses are performing care to a computerized adult mannequin when it suddenly indicates the "client" is choking and unable to breathe. During the feedback session, which action should the instructor point out as inappropriate?

Blind finger sweep at the beginning of the session

A nurse is preparing to defibrillate a client who is in ventricular fibrillation using an automated external defibrillator. After placing the paddles on the client's chest and turning the defibrillator on to analyze the rhythm, what should the nurse do next?

Call out "Clear!" in a loud voice.

The nurse places the pads of an automatic external defibrillator on an unresponsive, pulseless client and determines that the rhythm is ventricular tachycardia. Which action should the nurse take next?

Charge the machine, call out "Clear!" in a loud voice, and push the discharge button.

A nurse has been successful in clearing a client's complete airway obstruction using chest compressions. How should the nurse subsequently position the client to recover from this event?

in a side-lying position

The nurse witnesses a construction worker remodeling a hospital unit fall from the top rung of a ladder. 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?

jaw-thrust maneuver

A client is at risk for altered breathing. In which position will the nurse place the cient to optimize breathing?

Fowler

A nurse is performing the Heimlich maneuver on an adult client who has a total airway obstruction. Which action should the nurse perform to relieve the client?

Give five abdominal thrusts to the client.

The nurse is performing chest compressions on a client as part of cardiopulmonary resuscitation. The correct action of the nurse is:

maintaining her body over the hands during compressions and decompressions.

A small child requires CPR. Which technique would the nurse use to give rescue breaths?

mouth-to-nose

A hospital client has rung her call bell and told the nurse that the client in the bed next to hers has just been gasping for air and appears to have lost consciousness. The nurse quickly confirms that the client is indeed unconscious. What is the nurse's priority action?

Initiate cardiopulmonary resuscitation.

The nurse is the first person to arrive at the scene of an automobile accident. One of the victims was thrown from the vehicle and is nonresponsive. The nurse:

observes for the rising and falling of the victim's chest.

The victim is in a grocery store and has been successfully resuscitated after experiencing cardiac arrest. A nurse is present. The nurse places the victim:

on the left side with the arms and right leg brought forward.

A hospital nurse has responded to a colleague's call for help and found the colleague performing a rapid assessment of a client who is unresponsive. How should the nurse perform chest compressions during CPR?

Lock the fingers over the client's sternum and deliver straight-downward chest compressions.

A nurse who works in an outpatient clinic has not participated in a resuscitation effort for several years. What action should the nurse take to ensure preparedness in the event of a client's cardiac or respiratory arrest?

Maintain current certification in cardiac life support measures.

The nurse has performed cardiopulmonary resuscitation (CPR) on a client who was found not breathing and with a weak pulse in the waiting room of the emergency department. The client begins to cough and vomit after 15 seconds of CPR. While waiting for additional personnel to arrive, which action will the nurse take first?

Move the client into a side lying position on the ground in the waiting room.

The nurse has participated in cardiopulmonary resuscitation (CPR) for a client who had entered cardiac arrest. The nurse has just finished assessing for the presence of normal rise and fall of the chest with respirations. What is the nurse's next action?

Move the client into a side-lying position.

An infant with a small toy lodged in the trachea is crying. What is the nurse's priority action?

Observe the infant's respiratory effort.

A nurse is preparing to defibrillate a client brought into the emergency department in ventricular fibrillation (VF) using an automatic external defibrillator. After picking up the pads, what is the nurse's next action?

Place the gel pads on the precordium.

A nurse notices a colleague who has been involved in an unsuccessful code blue crying and visibly distraught. Which action by the nurse is most appropriate?

Provide support to the nurse by demonstrating empathy.

A nurse 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?

Start chest compressions.

A nurse is at a baseball game and responds when a person collapses. The nurse begins CPR and requests an automated external defibrillator (AED). The family is angry when the nurse stops compressions to apply the AED. What is the appropriate action?

Stop compressions for less than 10 seconds to apply the AED.

A nurse is working with children in a busy clinic. An infant is crawling around on the floor and begins coughing. What would indicated to the nurse that the problem is not an issue of total airway obstruction?

The infant begins crying.

A conscious client is showing evidence of total mechanical airway obstruction. Which step by the nurse is most appropriate?

Use chest thrusts to attempt to remove the obstruction.

Upon entering a client room, the nurse observes the client holding the base of the throat with both hands. The client is alert and appears anxious. The nurse notes the client has consumed 50% of the nearby meal tray. Which listed action will the nurse take first?

Wrap both arms around the client at chest level and thrust upward.

The nurse is performing resuscitation and is now checking for spontaneous breathing. The nurse makes this observation:

after five cycles of compressions and ventilations.

The victim is at a community event and has experienced cardiac arrest. The nurse is using an automatic external defibrillator (AED), which indicates that a shock should be delivered. The next action of the nurse is to:

ensure that no one is touching the victim.

A nurse is preparing to open a client's airway. The client has not sustained a head, neck, or spinal injury. Which would be most appropriate for the nurse to use?

head-tilt/chin-lift technique

A nurse is trying to determine if a client is conscious before beginning CPR. Which measure should the nurse try?

shaking the client

The nurse is at a community event when another attendee falls down. The nurse responds first by:

shaking the victim and asking, "Are you alright?"

The nurse is performing chest compressions on a pulseless older adult client. Which client history will place the client at risk for internal bleeding during the chest compressions?

takes a daily dose of anticoagulants

The client, upon admission to the hospital for a surgical procedure, asks for information about advance directives. The nurse gives information orally and in writing to the client. The best statement by the nurse is:

"Take a few days to think about what you desire."

A nurse is at a restaurant and hears another patron coughing. The patron is saying, "Please get me some water." The nurse's companion asks if the nurse should perform the Heimlich maneuver to help. Which response from the nurse is appropriate?

"The Heimlich maneuver will not be necessary for this person."

A nurse is preparing the care plan for a new resident at the long-term care facility. Which question should the nurse prioritize in the assessment after reviewing the client's medication history?

"What are your preferences related to advanced directives?"