Chapter 37: Resuscitation

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 most appropriate?

"I'll check on her, but the Heimlich maneuver is not necessary because the obstruction is not total."

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 is performing mouth-to-nose breathing to a 3-year-old child. Which of the following actions should the nurse perform for effective mouth-to-nose breathing?

Close the mouth and blow breath into the nose

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

Infant begins crying

A nursing class is reviewing the importance of health care legislation. What would a student correctly identify as the significance of the Patient Self-Determination Act of 1991?

It recognizes that the client has ultimate decision making about life-sustaining treatments.

A client requires rescue breathing. The nurse does not have a one-way valve mask available. What should the nurse do?

Perform rescue breathing without the device.

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

Performing the Heimlich maneuver

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 no one is touching the victim

Which of the following is a risk if a person who is inexperienced tries to perform the jaw-thrust maneuver?

Injuring the client's spine

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.

After applying the AED pads to a person, the AED displays an error message. Which action would be least appropriate?

Wipe the person's skin with a damp towel.

Which are common causes of airway obstruction? Select all that apply.

compromised swallowing aspiration of vomitus eating when intoxicated

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

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

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

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 nurse, upon admitting a client to a health care facility, asks the client if he has an advance directive. The client states that he does. The nurse next asks:

"Do you have a copy with you?"

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."

When performing rescue breathing during CPR, the nurse would deliver how many rescue breaths for every 30 compressions?

2

A nurse is administering chest compressions to assist the circulation of an unconscious person. How many compressions should the nurse give? Record your answer using a whole number.

30

A 10-year-old child is exhibiting signs of a partial airway obstruction. Which action would the nurse perform first?

Abdominal thrusts

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

Administer five abdominal thrusts.

A person is found on the floor and he is not breathing. A syringe is in his arm and signs of frequent intravenous drug use are present. What is the priority response?

Administer naloxone.

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

Administer naloxone.

A nurse is attending to a client who has had a cardiac arrest. Which step does the nurse do last in the chain of survival?

Early advanced life support

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

A nurse is administering chest thrusts to an infant. Where on the baby's body should the nurse perform these?

Middle of the breastbone, just below the nipple line

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

Mouth-to-nose

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.

The nurse enters a client's room, observes the client coughing vigorously, and determines that the client is breathing but has a partially obstructed airway. Which action should the nurse take next?

Observe the patient's respiratory effort.

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.

When performing chest compressions on an adult, the nurse would use which type of motion to be effective?

Straight downward pushing

A nurse has to perform subdiaphragmatic thrusts on an infant. Place the steps in this procedure in the correct order.

Support the baby over your forearm. Hold the infant prone with the head downward. Use the heel of one hand to administer five back slaps between the shoulder blades. Turn the infant supine. Use two finger sweeps to give five chest thrusts at approximately one per second to the middle of the breast bone.

A lead physician and a group of nurses are performing cardiopulmonary resuscitation (CPR) on an unconscious client with complete airway obstruction. When can CPR be interrupted on the client?

When the client regains a pulse

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

two fingers

After opening a person's airway, the nurse administers two rescue breaths. Which would the nurse interpret as indicating effectiveness?

visible rising of the chest

A nursing instructor is describing CPR techniques. During the discussion about rescue breathing, a student asks the instructor, "Why should we use a one-way valve mask?" Which response by the instructor would be most appropriate?

"The mask helps to reduce your risk for exposure to potential infectious diseases."

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 further in the throat."

A rescue team is using an AED to discharge shock, and then resumes CPR. For how many cycles would the CPR continue before the team analyzes the rhythm again with the AED? Record your answer using a whole number.

5

After teaching a group of nursing students about airway obstruction, the instructor determines that the teaching was successful when the students identify which of the following as a common cause? Select all that apply.

Aspiration of vomitus Laughing while chewing Eating while intoxicated

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 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 hospitalized adult client is unconscious and has an airway obstruction from a chunk of meat. Immediately prior to each ventilation attempt, the nurse:

looks in the client's mouth for the chunk of meat

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

Give five chest thrusts to the client.

The nurse determines an alert 9-month-old infant has a complete airway obstruction. Place the following actions that the nurse performs in the correct order, from first step to last.

Hold the infant prone with the baby's head in a downward position. Administer five slaps to the infant's back between the shoulder blades. Turn the infant to a supine position with the baby's head pointed down. Use two fingers to administer five thrusts on the chest below the nipple line.

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

While assessing a client who is unable to talk and is making high-pitched sounds while inhaling, the nurse witnesses the client lose consciousness. In which order will the nurse take these actions?

Lay the client down. Active the emergency medical system. Give five quick subdiaphragmatic upward thrusts. Open the client's airway. Check the client's mouth for any visible object.

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

Offer words of support and sympathy.

A nurse has placed the electrode pads of an automated external defibrillator (AED) on a client who is motionless in order to analyze the heart rhythm. Which of the following actions should the nurse perform next?

Press the analysis button on the AED

A nurse is teaching a cardiopulmonary resuscitation (CPR) class for health care providers. Which information is appropriate to include in the teaching plan? Select all that apply.

Rescue breathing for infants is completed at the rate of two breaths for every 15 compressions when administered by two trained rescuers. During cardiopulmonary resuscitation, each breath should be given over 1 second After five cycles compressions and breathing an automated external defibrillator is attached.

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 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.

The nurse determines that defibrillation of a client was successful based on which observations?

The client is awake, HR 88 sinus rhythm with occasional PVCs, respiratory rate 16.

A student nurse hears another nurse use the term "cardiac arrest." What does the student understand this to mean?

The heart has either stopped contracting or having a life-sustaining heart rhythm.

The nurse is performing cardiopulmonary resuscitation on a victim on the golf course. For how long does the nurse continue the efforts? Select all that apply

The victim exhibits a pulse and respirations. The nurse becomes too exhausted to continue. Emergency medical technicians (EMTs) or paramedics arrive.

Two rescuers are performing CPR on an adult victim. Which observation would cause the by-standing nurse to intervene?

There are two rescue breaths for every 15 compressions.

Health care personnel are attempting to resuscitate an unconscious client. What factors contribute to the decision to stop their efforts? Select all that apply.

Time that elapsed before resuscitation was begun Time since resuscitation started with no change in the victim's condition Client's age Client's medical diagnosis

Following a successful resuscitation, what are the nurse's priority interventions. Select all that apply.

administering oxygen to maintain PaO2 greater than 94% continuous cardiac monitoring of rate and rhythm monitoring blood pressure to keep systolic BP above 90 mm Hg maintain client's body temperature to within a range of 89.6° F to 96.8°

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

after five cycles of compressions and ventilations

A person is choking but conscious. The nurse knows that the primary determinant of how to perform thrusts to help dislodge the obstruction is the victim's:

age.

The nurse is assisting with administration of rescue breaths during cardiopulmonary resuscitation (CPR) by the CPR team. The adult client has an endotracheal tube in place. The nurse administers a breath:

at a rate of 8 to 10 breaths per minute

A nurse is assessing a client with partial airway obstruction. Which signs should the nurse observe if a client has partial airway obstruction? Select all that apply.

exhibits cyanosis makes wheezing sounds coughs when eating

The nurse is providing care to a 6-month-old infant hospitalized with respiratory distress. The infant has stopped breathing. While providing CPR, the nurse:

performs compressions at the rate of 100/minute.

A nursing student is demonstrating chest compressions for an adult. Which action would cause the nurse to intervene?

placing the heel of the hand just below the xiphoid process

The nurse suspects that a person has experienced cardiac arrest. The nurse shakes the person and asks in a loud voice, "Are you okay?" The nurse is assessing:

responsiveness.

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

shaking the victim and asking, "Are you all right?"

Which of the following is the correct way for the nurse to place a client to ensure the client is in the "recovery position?"

side

Following a successful resuscitation on an older adult client, what should the nurse assess for? Select all that apply.

stroke fractured ribs papillary edema

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

2 inches.

A rescue team has been performing chest compressions and is moving to defibrillation. Within how many minutes should defibrillation start to enhance the best outcomes? Record your answer using a whole number.

3

A nurse is learning about mechanical airway obstruction. Place the steps of airway obstruction in the correct sequence.

A bolus of food or some other foreign object becomes trapped. Obstruction compromises air exchange. Obstruction inhibits oxygenation of cells and tissues. Client loses consciousness. Client dies.

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

A nurse is caring for a client who has just had an endotracheal tube advanced airway inserted and is being oxygenated by a ventilator. When the ventilator sounds an alarm, the nurse finds the client lying in bed holding the endotracheal tube in his hand. Which action should the nurse take?

Manually ventilate the client with 100% oxygen.

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 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