Chapter 16: Care of Patients Experiencing Urgent Alterations in Health

The HCP informs a patient's wife that her husband has suffered brain death and is in an irreversible coma, even though his heart is still beating. Which comment indicates that the wife has understood what the HCP said? 1. "His heart is still beating, so there is still a chance he'll recover." 2. "He is in a coma, but do you think that he can hear what I say?" 3. "I must notify the family so that everyone can come and say goodbye." 4. "How long do you think he will have to stay in the intensive care unit?"

"I must notify the family so that everyone can come and say goodbye." Rationale: The wife is acknowledging that it is time to say goodbye. It is not uncommon for families to need additional time at the bedside when someone dies. The other statements indicate a belief or hope that he can still recover

During a camping trip, a person who is allergic to bee stings is stung by a bee. The nurse immediately scrapes the skin to remove the stinger. Which questions would the nurse ask first? 1. "What happens when you get stung by a bee?" 2. "Do you want to go to the hospital?" 3. "Where is your epinephrine pen?" 4. "Do you have any diphenhydramine?"

"Where is your epinephrine pen?" Rationale: A person with a known allergy to bee stings is supposed to carry an epinephrine pen and the pen should be immediately available in case the person has an anaphylactic reaction or becomes unconscious or unable to speak. If a pen is not available, taking diphenhydramine and immediately seeking medical assistance would be the next best thing. Discussions about past episodes of allergic reaction should not delay treatment or seeking medical assistance. Allergic reactions can be progressively worse with repeated exposures to allergens.

Which patient has the best chance to fully recover because of the nurse's actions? 1. 4-year-old drowns; nurse starts CPR within 4 minutes of clinical death. 2. 32-year-old with brain death has a cardiac arrest; nurse starts CPR within 2 minutes. 3. 17-year-old with biologic death has a respiratory arrest; nurse immediately delivers rescue breaths. 4. 55-year-old is electrocuted; nurse starts CPR within 10 minutes of clinical death

4-year-old drowns; nurse starts CPR within 4 minutes of clinical death. Rationale: Clinical death means that the heartbeat and breathing have stopped. If CPR is started within 4 minutes, tissue is spared and condition can be reversed. In brain death or biologic death, the damage is permanent. A delay of 10 minutes in initiating CPR is likely to result in brain death

The nurse is caring for an adult patient with severe burns covering his face, anterior of his chest, and anterior and posterior of both his arms. Using the Rule of Nines, what percentage of this patient's body is burned? 1.) 50% 2.) 60% 3.) 40.5% 4.) 45%

40.5% Rationale: Using the Rule of Nines, the face equals 4.5%, the anterior chest equals 18%, and the anterior and posterior of both arms equal 18% for a total of 40.5%.

Using the Rule of Nines to determine how much of the body surface is burned for an adult patient who has severe burns to the anterior and posterior thorax and both upper extremities.

54% Rationale: Anterior thorax =18%, Posterior thorax= 18%, both upper extremities= 18%= Total burned surface= 54%

Which patient has the greatest risk for internal bleeding? 1. A 20-month-old child who stumbled and struck his forehead on a coffee table 2. A 70-year-old woman sustained a hip fracture and takes an anticoagulant 3. A 25-year-old man who was punched and kicked in the stomach 4. A 30-year-old woman who was admitted for postpartum hemorrhage

A 70-year-old woman sustained a hip fracture and takes an anticoagulant Rationale: All of these patients are at risk for internal bleeding; however, for patients who are on anticoagulants, fractures of hip or femur can result in 500-1500 mL of blood loss.

Which assessment finding confirms cardiac arrest? 1. Absence of radial pulse 2. Absence of carotid pulse 3. Absence of spontaneous respirations 4. Unresponsiveness to normal stimuli

Absence of carotid pulse Rationale: Absence of a carotid pulse is indicative of cardiac arrest. The peripheral pulses are not as strong and blood flow to extremities will decrease to preserve the brain and heart. It is possible for respirations to cease while the heart continues to beat (e.g., choking or drowning); however, cardiac arrest will quickly follow respiratory arrest. There are many reasons for decreased responsiveness (e.g., diabetic coma, stroke, drug overdose, electrolyte imbalance) where the heart will continue to beat.

A person sustains full-thickness burns to both forearms while lighting an outdoor grill. The nurse would intervene if a bystander attempts to perform which action? 1. Removes smoldering clothing 2. Removes victim's wedding ring 3. Applies an antiseptic cream to the burns 4. Places forearms in cold water

Applies an antiseptic cream to the burns Rationale: No creams, ointments, sprays, or other topical applications should be put on the skin. The skin will have to be assessed and cleaned at the hospital and topical applications can create complications. The other actions are correct.

A patient comes into the emergency department with an open wound on the right leg. There is a large piece of tissue missing, leaving the tendon and muscles exposed. This is an example of which type of open wound? 1. Laceration 2. Incision 3. Avulsion 4. Puncture

Avulsion Rationale: An avulsion is a torn piece of tissue that results in a section being completely removed or left hanging by a flap. Underlying bones, tendons, or muscles may be exposed. A laceration is a wound that has jagged, irregular edges caused by auto accidents, blunt objects, or heavy machinery. An incision is a smoothly divided wound made by sharp instruments. A puncture is a piercing wound of the skin caused by knives, nails, wood, glass, or other objects that penetrate the skin.

Upon entering the room of a female patient, the nurse assesses her to be unresponsive, not breathing, and with no pulse, and immediately calls for assistance. What is the next nursing action? 1. Call the health care provider. 2. Begin chest compressions. 3. Apply oxygen. 4. Open the patient's airway.

Begin chest compressions. Rationale: The nurse should begin compressions. A health care provider being called falls in the area of calling for assistance, which has already been done. Oxygen may be provided at some point but would not be the next nursing action. Reassessment of airway may occur after compressions are started or once assistance arrives.

A mother calls her friend who is a nurse and says that her child has ingested furniture polish. What should the nurse tell the mother to do? 1. Take the child to the emergency room. 2. Call the Poison Control Center. 3. Call 911 for an ambulance. 4. Give ipecac syrup to induce vomiting.

Call the Poison Control Center. Rationale: The mother should call the Poison Control Center immediately to receive instructions as to what to do. Taking the child to the emergency room or calling 911 for an ambulance would not be the first intervention because it could delay treatment. The mother should not give ipecac until instructed to do so by Poison Control. Vomiting may not be the appropriate action for this type of poisoning.

The nurse arrives outside of the public library and finds a person lying on the ground. What is the first action to take? 1. Check if the victim is unconscious. 2. Check the carotid or brachial pulse. 3. Move the victim to a flat, hard surface. 4. Direct someone to call 911.

Check if the victim is unconscious. Rationale: First, the nurse assesses level of consciousness. Based on the assessment, the nurse may decide to question the person, start CPR, call 911, or check for injuries.

The nurse is caring for a patient who may have a cervical spine injury. The patient is lying flat and begins to vomit. What would the nurse do? 1. Use an oral suction catheter to remove vomitus and direct the patient to hold breath during suctioning. 2. Direct the patient to look straight ahead and not move his neck, then sit him up-right using the bed mechanism. 3. Direct several people, acting together as one unit, to help logroll the victim onto his side to allow drainage. 4. Immediately report vomiting to the HCP and ask if cervical spine injuries have been ruled out.

Direct several people, acting together as one unit, to help logroll the victim onto his side to allow drainage. Rationale: Several people acting together should logroll the patient. A nurse or HCP should control and maintain the position of the head and neck during the roll.

The nurse hears a scream; a patient has slipped in the bathroom. There is bright-red blood spurting from her forearm. What would the nurse do first? 1. Don sterile gloves and apply firm pressure using a sterile gauze pad. 2. Use layers of sterile dressing material and wrap them snugly with an elastic bandage. 3. Don clean gloves and use a clean towel to apply direct pressure; elevate the arm. 4. Locate the brachial artery and use the heel of the hand to compress the artery.

Don clean gloves and use a clean towel to apply direct pressure; elevate the arm. Rationale: The patient has an arterial bleed, so the nurse would not waste time seeking out sterile supplies. Clean gloves and a clean towel are adequate. Elevation above the level of the heart will also help control the bleeding. Wrapping the area with layers of sterile gauze would be done after initial bleeding is controlled. Pressure to the brachial artery would only be done if direct pressure and elevation were not controlling bleeding.

A car accident victim was ejected from the car. It has been determined that his airway needs to be opened. What is the most appropriate method for the rescuer to use? 1. Jaw thrust/chin lift 2. Head tilt/chin lift 3. Flexed position 4. Modified head tilt/chin lift

Jaw thrust/chin lift Rationale: If a neck injury is suspected, the jaw thrust/chin lift is used. If neck injury is suspected, the head tilt/chin lift produces hyperextension of the neck and could cause complications. A flexed position is an inappropriate position to open an airway.

The patient has a sutured laceration on the palmar surface of the hand. When will the supervising nurse intervene? 1. The student nurse positions the hand in the anatomical position before applying the bandage. 2. The student nurse covers the entire wound with the dressing and roller gauze is applied uniformly. 3. The student nurse applies roller gauze with a number of evenly spaced overlapping turns. 4. The student nurse covers the tips of the fingers with the gauze bandage and secures roller gauze with tape.

The student nurse covers the tips of the fingers with the gauze bandage and secures roller gauze with tape. Rationale: Tissue distal to the wound, in this case the fingers, should not be covered. This allows the nurse to assess capillary refill, skin temperature, and finger joint movement. The other actions are correct.

From the following list, what are the events that require CPR? (Select all that apply.) 1. Drowning 2. Hypothermia 3. Asphyxiation 4. Heatstroke 5. Sudden infant death syndrome

1. Drowning 3. Asphyxiation 5. Sudden infant death syndrome Rationale: Events that require the rescuer to assess the ABCs of cardiopulmonary resuscitation and initiate necessary interventions include cardiac arrest, drowning, electrical shock, anaphylactic reaction, asphyxiation, drug overdose, and sudden infant death syndrome. CPR may not always be required with hypothermia or heatstroke.

Which interventions are appropriated for a victim who is in hypovolemic shock at the scene of an accident? Select all that apply. 1. Establish airway. 2. Control bleeding 3. Keep the head elevated. 4. Cover with a blanket or coat. 5. Provide oral fluids, such as water. 6. Administer over-the-counter analgesics.

1. Establish airway. 2. Control bleeding 4. Cover with a blanket or coat. Rationale: Immediate measures are to establish an airway and control bleeding. Body temperature should be maintained, so covering the person helps minimize heat loss. The head should not be elevated, because this will decrease perfusion to the cerebrum. Also, spinal precautions would be applied if head or neck injuries are suspected. Oral fluids are typically withheld. Intravenous fluids would be started if available. No medication should be given at the scene of the accident.

When performing chest compressions on a child, the breastbone is compressed to the depth of: 1.) 0.5 in. 2.) 1.5 in. 3.) 2 in. 4.) 2.5 in.

1.5 in. Rationale: The chest is compressed with the heel of one hand at a depth of 1.5 in at 100 times per minute; 0.5 in is not a deep enough compression for a child. 2 in is too deep a compression for a child; 2.5 in is too deep a compression for a child.

What is the most commonly abused drug in the world? 1. Illegal drugs 2. Prescriptions medications 3. Alcohol 4. Over-the-counter medications

Alcohol Rationale: Alcohol, a CNS depressant, is the most commonly abused drug in the world. It is easily available, and causes many adverse reactions, even death.

The nurse comes home and finds that her teenage son and his friends have been challenging each other to chug large shots of whiskey. Which adolescent needs to be taken to the hospital for serious alcohol intoxication? 1. Face appears flushed and seems sleepy. 2. Demonstrates slurred speech and continuously giggles. 3. Is loudly singing and starting to remove clothes. 4. Is incontinent of bowel and bladder and is hallucinating

Is incontinent of bowel and bladder and is hallucinating Rationale: Loss of bowel and bladder function, rapid and weak pulse, labored breathing, seizures, nausea, vomiting, diarrhea, loss of memory, lack of coordination, and depressed muscle reflexes are signs of serious intoxication. The other adolescents are demonstrating signs and symptoms of mild intoxication.

Older adults are at risk for drug overdose. What is the main physiologic change of aging that can lead to overdose? 1. Hearing 2. Eyesight 3. Weakness 4. Smell

Eyesight Rationale: The main physiologic change that may contribute to overdose is eyesight. Changes leading to decreased vision lead to taking the medication inappropriately. Older adults with hearing loss, chronic weakness, or an impaired sense of smell may still be able to read the labels of their medications in order to take them appropriately.

The nurse initiates CPR on a frail older woman who has cardiac arrest. During the compressions, the nurse hears and feels the cracking of the ribs. What would the nurse do? 1. Change hand position and then continue compressions. 2. Stop compressions and assess for crepitus or flail chest. 3. Stop compressions but continue to deliver the rescue breaths. 4. Verify correct hand position and continue compressions.

Verify correct hand position and continue compressions. Rationale: Nurse verifies hand position; incorrect hand position increases the chance for factures, but even with correct positioning, fracturing the ribs is a possibility, especially in frail older adults. Resuscitation efforts should continue.

What would be included in a teaching plan for safety and response to an emergency in the home environment? Select all that apply. 1. Keeping poisons locked away from children. 2. Maintaining a list of emergency phone numbers. 3. Keeping electrical cords in good repair with no fraying. 4. Teaching family members how to do cardiopulmonary resuscitation (CPR) 5. Identifying and obtaining emergency first-aid supplies and instructions. 6. Reviewing use of handrails and removal of loose rugs or other obstacles.

1. Keeping poisons locked away from children. 2. Maintaining a list of emergency phone numbers. 3. Keeping electrical cords in good repair with no fraying. 5. Identifying and obtaining emergency first-aid supplies and instructions. 6. Reviewing use of handrails and removal of loose rugs or other obstacles. Rationale: The teaching plan should include keeping emergency first aid supplies and instructions and maintaining a list of emergency phone numbers. Accident-proofing the home: store poisons locked away from children, use handrails, use nonskid surfaces, have good lighting, and practice electrical safety (e.g., check electrical appliances for frayed cords). If family members are interested in learning CPR, the best thing to do would be to refer them to American Red Cross.

A young man, who is injured, is brought to the clinic by his friends. They are all very excited, but they are able to point out that he has a stick poking out of the anterior chest wall. Which symptoms indicate that the patient has a pneumothorax? Select all that apply. 1. Pain worsens with inspiration and expiration efforts. 2. Breathing is labored and difficult. 3. A hissing sound is audible as air flows in and out of his chest. 4. The patient is unconscious and unresponsive to normal stimuli. 5. Pulse is weak, rapid, and thready. 6. His chest does not expand on the side of injury during inspiration.

1. Pain worsens with inspiration and expiration efforts. 2. Breathing is labored and difficult. 3. A hissing sound is audible as air flows in and out of his chest. 5. Pulse is weak, rapid, and thready. 6. His chest does not expand on the side of injury during inspiration. Rationale: Respiratory distress, pain, and decreased perfusion are signs/symptoms of a pneumothorax or hemothorax. This patient could be unconscious and unresponsive if hemorrhage is excessive blood or if decreased oxygenation of brain tissue has occurred; however, patients with a hemothorax or pneumothorax are frequently conscious and experiencing pain, anxiety, and severe respiratory distress.

The nurse is at a community event and several people are injured when a large tent structure is blown over by the wind. Which information is essential to convey when calling the emergency medical system (EMS) for help? Select all that apply. 1. "I am a nurse; I work at a local hospital, and I have basic life support (BLS) certification." 2. "One woman's legs are trapped under a heavy beam; she is alert and breathing." 3. "Three children appear to have minor abrasions; one child's arm was splinted for possible fracture." 4. "An older man with 'heart problems' is short of breath but has no external injuries." 5. "A large tent structure in the city park has fallen and five people have been injured." 6. "The parking lot is congested; the best access is on the south side of the park."

2. "One woman's legs are trapped under a heavy beam; she is alert and breathing." 3. "Three children appear to have minor abrasions; one child's arm was splinted for possible fracture." 4. "An older man with 'heart problems' is short of breath but has no external injuries." 5. "A large tent structure in the city park has fallen and five people have been injured." 6. "The parking lot is congested; the best access is on the south side of the park." Rationale: The caller should identify self and location. State that structure collapsed and several people were injured. State possibility of ongoing danger related to the unstable structure. The nurse does not need to state credentials or work background in the immediate report. Later, as needed, the EMS operator or personnel may ask the nurse to give credentials

The nurse is performing CPR on an infant. What is the most common event that could occur? 1. Fracture of the rib. 2. Gastric distention 3. Aspiration of emesis 4. Laceration of spleen

Gastric distention Rationale: For infants, gastric distention is common because an excessive amount of air is delivered during rescue breathing. To prevent this, the amount of air that is held in the nurse's cheeks is given during each rescue breath.

An infant is observed picking up something from the floor and putting it into his mouth before the mother can stop him. He demonstrates coughing, gagging, stridor, and respiratory distress. What would the nurse do first? 1. Instruct the mother to hold the child and look into the mouth with a flashlight. 2. Place the infant in a supine position and deliver five chest thrust. 3. Place two fingers just above the navel and deliver five abdominal thrusts. 4. Hold the infant with the head lower than trunk and deliver five back blows.

Hold the infant with the head lower than trunk and deliver five back blows. Rationale: For infants, use five back blows, turn him over and deliver five chest thrusts. For back blows and chest thrusts, head should be lower than the trunk. See Figure 16.9. If the object is expelled during blows or thrusts and the head is downward, gravity will help. Using a flashlight and looking in the mouth will delay the intervention of clearing the airway. The child is likely to struggle out of fear and respiratory distress and visualizing the back of the mouth will be difficult. (Stridor definition: A high-pitched, whistling sound most often heard while taking in a breath.)

The nurse is on a hiking trip and one of the children finds an injured bat and picks it up. The bat bites the child before any of the adults can intervene. What would the nurse do first? 1. Monitor for shock and seek medical attention immediately. 2. Capture the bat and observe for injury or signs and symptoms of disease. 3. Immediately and thoroughly wash the bite area with soap and water. 4. Assess for and control bleeding and apply a thick gauze bandage.

Immediately and thoroughly wash the bite area with soap and water. Rationale: Studies show that thorough wound cleansing markedly reduces the incidence of rabies. It would be appropriate to capture the bat if it can be done safely and quickly; then take the child and the bat (for rabies testing) and seek medical assistance.

The nurse is assessing a trauma patient who was treated for shock in the emergency department. Oliguria is noted and immediately reported to the HCP. Which complication is most related to this finding? 1. Right-sided heart failure 2. Kidney failure 3. Paralytic ileus 4. Electrolyte imbalance

Kidney failure Rationale: Oliguria is urine output less than 500 mL in 24 hours. During shock, blood flow to the kidneys is decreased. This can result in damage to the kidneys. Paralytic ileus is decreased or absent motility of the bowel, which can also occur with shock; however the appropriate assessment would be bowel sounds, abdominal pain, or failure to pass gas or stool. Shock can also produce electrolyte imbalance, but assessment of laboratory values would be more appropriate than observing amount of urine output. Heart failure is the least likely complication of shock. Right-sided heart failure is more associated with long-term respiratory or circulation problems.

The person gives the universal sign for choking. How does the nurse prepare to perform abdominal thrust? 1. Instructs the person to lean over the back of a chair. 2. Places the fist over the sternum. 3. Places the fist slightly above the navel. 4. Puts the heel of the hand over the xiphoid process.

Places the fist slightly above the navel. Rationale: Placing the fist just above the navel is the position to create enough force to expel the foreign body, and to avoid fracturing underlying bone structures. Bending over the back of a chair is a method that should be tried if a person is alone and unable to summon assistance.

Under what circumstances would the nurse use a tourniquet? 1. The nurse is acting in good faith and conforms to Good Samaritan principles. 2. The HCP gives a telephone order to apply a tourniquet. 3. The victim tells the nurse to apply a tourniquet. 4. Pressure and elevation have failed to control life-threatening bleeding.

Pressure and elevation have failed to control life-threatening bleeding. Rationale: If direct pressure, elevation, and indirect pressure have failed to control bleeding and the patient's life is in danger, the nurse would use a tourniquet. Use of a tourniquet should not be considered part of general first aid or the Good Samaritan principles. An HCP could order the application of a tourniquet over the phone or the victim could request it; however, as with other procedures that are not within the scope of practice, the nurse should decline unless he/she deems that the patient's life is in jeopardy.

The home health nurse sees the patient lying on the floor. On entering the house, the nurse can smell a strong odor of gas and the house is extremely hot. What would the nurse do first? 1. Step out of the house and call 911. 2. Call Poison Control and describe the situation. 3. Establish responsiveness and start cooling measures. 4. Open the windows and move the patient out of the house.

Step out of the house and call 911. Rationale: The nurse cannot immediately determine if the patient has been overcome by gas or heat, or by something else; however, for the nurse's safety, he/she steps out of the house and calls 911. If the nurse is overcome by gas and help has not been summoned first, the nurse and the patient could die.

The nurse is teaching basic CPR to a new group of unlicensed assistive personnel (UAP). When would the nurse intervene? 1. The UAP leans forward over the mannikin and creates pressure to depress the sternum at least 2 inches (5 cm). 2. The UAP compresses at a rate 100 to 120 compressions per minute without pausing between compressions. 3. The UAP places the heel of one hand over the lower end of the sternum and places heel of the other hand on top. 4. The UAP interlaces fingers to keep them off the chest and keeps hands in contact with the chest.

The UAP places the heel of one hand over the lower end of the sternum and places heel of the other hand on top. Rationale: Heel of the hand should be placed over the center of the sternum between the nipples. This position decreases the likelihood of fracturing the xiphoid process or ribs or lacerating an organ and maximizes the compression action over the heart.

Which patient has a condition that could resemble brain death? 1. The patient has a blood alcohol level of 0.05%. 2. The patient has a core temperature below 30° C (86° F) 3. The patient has oliguria secondary to hypovolemic shock 4. The patient fainted and was unconscious for 5 minutes

The patient has a core temperature below 30° C (86° F) Rationale: Hypothermia, anesthesia, poisoning, or drug intoxication can resemble brain death. A core temperature below 30° C (86° F) results in lowered metabolic rate and patients may appear dead but should be slowly warmed and CPR may be needed. A blood alcohol level of 0.05% is mild intoxication. With mild alcohol intoxication, oliguria hypovolemia, or fainting, breathing should continue. Pulse may be weak or irregular during hypovolemia or fainting.

For an unconscious adult victim with a foreign body airway obstruction, what would the nurse do? 1. Apply a series of three quick chest thrusts. 2. Repeat 10 abdominal thrusts and attempt to ventilate. 3. Perform finger sweeps between abdominal thrusts. 4. Visually look for object each time before providing a breath.

Visually look for object each time before providing a breath. Rationale: The nurse would visually inspect the mouth for an object, open the airway, and attempt to ventilate. If ventilation is not possible, deliver five abdominal thrusts; then look in the mouth for foreign object and repeat sequence until object is dislodged and breathing resumes. If spontaneous breathing does not resume, the nurse would initiate CPR.

The health care provider (HCP) directs the nurse to call Poison Control to get advice for a patient who comes to the health care facility for "feeling sick after spraying an enclosed area with insect spray." What information is necessary to report when calling Poison Control? Select all the apply. 1. Patient is 20 years old. 2. He weighs 160 lbs (72.6 kg). 3. He is currently alert, nauseated, and has a mild headache (4/10) 4. He started to feel dizzy and nauseated after spraying an enclosed area with insect spray. 5. His symptoms started at 10 AM; this was several minutes after he started to use the spray. 6. He was not using any personal protective equipment (PPE) when he applied the spray. 7. He reports that his father used the same spray last week and had no problems.

1. Patient is 20 years old. 2. He weighs 160 lbs (72.6 kg). 3. He is currently alert, nauseated, and has a mild headache (4/10) 4. He started to feel dizzy and nauseated after spraying an enclosed area with insect spray. 5. His symptoms started at 10 AM; this was several minutes after he started to use the spray. 6. He was not using any personal protective equipment (PPE) when he applied the spray. Rationale: Necessary information includes all of the above, amount of substance taken, and any medications patient has taken. The father's use of the spray is not useful information for Poison Control, because the circumstances (ventilation, use of PPE, proximity of spray to face or mucous membranes, and user error) could be different. In some cases, such as suspicion of food poisoning, it is useful to report that others ate the same food at the same time.

Two nurses are shopping together in a mall and they witness a person collapse and become unresponsive. Based on assessment, they initiate two-rescuer CPR. Under which circumstances can the two nurses discontinue the CPR? Select all that apply. 1. A relative of the unresponsive person tells them to stop. 2. Mall personnel arrive with the automated external defibrillator (AED). 3. The curious crowd pushes in and bystanders are loud and unruly. 4. Trained medical personnel arrive and take over CPR. 5. The person remains unconscious but spontaneous pulse and breathing occur. 6. A layperson offers to take over the role of doing compressions.

2. Mall personnel arrive with the automated external defibrillator (AED). 4. Trained medical personnel arrive and take over CPR. 5. The person remains unconscious but spontaneous pulse and breathing occur. Rationale: CPR can be stopped to apply the AED, and for trained personnel to take over. If the person is spontaneously breathing and has a pulse, CPR should be discontinued even if the person remains unconscious. Pulse and breathing should be continuously monitored. The nurses should not trade off with a layperson unless they are exhausted and unable to continue with CPR. Trading causes delay. In addition, the nurses are more likely to have experience, recent training, and better compression technique than a lay rescuer. The nurses should not be distracted by the relative or the crowd. CPR requires intense effort and timing. The nurses could stop if the relative or crowd were threatening their personal safety.

What are the signs and symptoms of hypothermia? Select all that apply. 1. Bounding, rapid pulse 2. Uncontrollable shivering 3. Slow, slurred speech 4. Disorientation and confusion 5. Uncoordinated or decreased muscle control 6. Mottled skin

2. Uncontrollable shivering 3. Slow, slurred speech 4. Disorientation and confusion 5. Uncoordinated or decreased muscle control 6. Mottled skin Rationale: Hypothermia is demonstrated by uncontrollable shivering; low body temperature; slow, slurred speech; disorientation; and uncoordinated or decreased muscle movement. The skin may appear mottled and edematous (swelling), with general numbness. Pulse is weak and irregular, with depressed respiratory rate. The victim becomes more lethargic with decreasing level of consciousness until reflexes are also lost.

A patient is unresponsive to normal verbal stimuli and not breathing. How does the nurse assess for a carotid pulse? 1. Assess the location of the pulse for a maximum of 5 seconds. 2. Check strength of the pulse for 5 seconds and then compare it to the opposite side. 3. Assess the pulse rate for 10 seconds and then check for 3-second capillary refill. 4. Check the rate, rhythm, and strength of the pulse for a maximum of 10 seconds.

Check the rate, rhythm, and strength of the pulse for a maximum of 10 seconds. Rationale: Health care professionals, including nurses, should check for a carotid pulse, but for no longer than 10 seconds

The nurse is caring for a patient with a suspected fracture of his right arm. What is the most appropriate nursing action? 1. Trying to realign the bone 2. Immobilizing by splinting the bone as is 3. Assessing circulation above the injury 4. If the skin is broken, allowing injury to bleed

Immobilizing by splinting the bone as is Rationale: The nurse should not attempt to realign the bone, but immobilize it as is. Circulation needs to be assessed below the injury and any bleeding stopped. The nurse should not attempt to realign the bone.

The nurse finds a person lying at the bottom of a long staircase. The person is conscious but appears dazed and confused. There are no obvious injuries or signs of bleeding. What would the nurse do first? 1. Assist the person to sit up and suggest that he rest on a step. 2. Instruct the person to remain still and ask for permission to assist. 3. Initiate spinal cord precautions and hold head and neck in alignment. 4. Ask the person what happened and if he is having pain or distress.

Instruct the person to remain still and ask for permission to assist. Rationale: The person should not be moved, but since he is conscious it would be appropriate for the nurse to identify self and ask for permission to help. Resist the impulse to assist the person into a sitting or standing position. (Person may also be attempting to get up.) Initiating spinal precautions is correct; however, failure to ask permission or explain actions could be interpreted as an attack, especially if the person is confused and the nurse is a stranger to him/her. Asking the person about pain, symptoms, and events is appropriate after he is calm, immobile, and help has been summoned.

An older patient comes to the clinic for epistaxis. It is readily controlled with steady pressure applied to the bridge of the nose. Which additional assessment is most important for this patient? 1. Measuring the blood pressure 2. Assess self-care and hygiene 3. Ask about first-aid measures 4. Checking an oral temperature

Measuring the blood pressure Rationale: The nurse should assess all of the options; however, for older patients, hypertension is a primary risk factor. If hypertension is the underlying cause, the blood pressure is likely to be very high. Because the bleeding was easily controlled, the nurse suspects that the patient did not know how or could not perform the first-aid measures to stop the bleeding, so knowledge and skill must be assessed. Infections can also contribute to nosebleeds, so checking the temperature would also be appropriate (Epistaxis definition: nosebleed)

It's the Fourth of July and the nurse is working at a walk-in clinic. Several people who were viewing a parade come in and report abdominal cramp, headache, weakness, nausea, and diaphoresis. All are alert and oriented. Which intervention would the nurse use first? 1. Establish peripheral intravenous sites on everyone. 2. Give everyone several cool compresses. 3. Assist everyone to remove constrictive clothing. 4. Move everyone into a cool environment.

Move everyone into a cool environment. Rationale: Victims are first moved into a cool environment. Next, the nurse would assist to remove constrictive clothing, offer cool drinks, and give cool compresses. A circulating fan will also help.

Which sign or symptom of a foreign body airway obstruction is of greatest concern? 1. Patient says, "I think I swallowed something." 2. Patient is coughing so hard that he can't speak. 3. Patient makes a wheezing sound between coughs. 4. Patient demonstrates a high-pitched inspiratory noise.

Patient demonstrates a high-pitched inspiratory noise. Rationale: A high-pitched inspiratory noise suggests that there is an object in the airway that is allowing a small amount of air to go around the object. This is an emergency because the object could become lodged and allow no air movement. If the person can speak, this means that air is passing over the vocal cords and into the airway. Forceful coughing is a good sign because it is the most effective means for the person to independently rid the airway of a foreign body. If the person is coughing, rescuer would not interfere, even if some wheezing is heard

Which patient is most likely to need a tetanus toxoid injection? 1. Patient fell off a bike and has abrasions on the knee, last known tetanus shot was several years ago. 2. Patient sustained a puncture wound from stepping on an old nail that went through his workboots. 3. Patient was elbowed during a basketball game and has swelling and ecchymoses on right lateral chest. 4. Patient sustained a deep cut on the hand while washing a drinking glass; there was extensive bleeding.

Patient sustained a puncture wound from stepping on an old nail that went through his workboots. Rationale: Patients who sustain puncture wounds should have a tetanus toxoid injection unless they had one within the past 10 years. Patients with closed wounds do not need tetanus shots. The patient who was cut by a drinking glass is also likely to get a tetanus shot, but the wound bled freely, and the drinking glass is a less likely source of tetanus compared to a dirty object such as a nail. (Ecchymoses definition: bruises)

The nurse notes heavy spurting of bright-red blood from the patient's groin area after he returns from an arteriogram procedure. The nurse dons clean gloves and applies gauze and direct pressure. The gauze is quickly saturated. What would the nurse do first? 1. Increase the patient's IV fluid, take vital signs, monitor bleeding, and notify the HCP. 2. Place an additional layer of gauze on top of the saturated dressing and continue to hold pressure. 3. Elevate the hips and apply more pressure over the groin area; ask someone to check a distal pule. 4. Apply a pressure bandage and monitor distal pulses, sensation, and temperature of the skin.

Place an additional layer of gauze on top of the saturated dressing and continue to hold pressure. Rationale: For active arterial bleeding, place additional gauze on top of the saturated dressing and continue to hold pressure. The nurse could ask another nurse to check pulses or call the HCP. Taking vital signs can be delegated to UAP. Elevating the hips is impractical and applying a pressure dressing over the groin area would be difficult. Once the bleeding has stopped, monitoring for rebleeding and for distal perfusion is appropriate action.

The latest recommendation for CPR is to go "hard and fast" when performing chest compressions. What is the best rationale for maintaining the recommended 100-120 compressions/minute? 1. The rescuer will become fatigued if compressions exceed 100/minute. 2. Lacerations of the liver or spleen are more likely to occur if speed is excessive. 3. Releasing external chest compressions allows time for blood to flow back into the heart. 4. A smooth motion is required to prevent rocking and rolling that decrease the force.

Releasing external chest compressions allows time for blood to flow back into the heart. Rationale: The goal of CPR is to mimic the pumping action of the heart and if compressions are too rapid and the heart is not allowed to fill with blood, there is nothing to pump out. The rescuer will become fatigued even if the proper rate is maintained; altering the speed of compressions is not the solution. Lacerations or fractures are more associated with proper hand position than speed of compressions. A smooth motion is more related to proper position of arms and hands in relation to the victim's body. Rescuer fatigue could also contribute to smoothness of movements.

For the unconscious victim with hypothermia, which intervention can be provided at the scene? 1. Give small sips of warm liquid very slowly. 2. Remove wet clothes and wrap in warm blankets. 3. Submerge the victim in a warm tub of water. 4. Gently rub extremities to stimulate circulation.

Remove wet clothes and wrap in warm blankets. Rationale: Victim should be moved to a warm environment if possible and wet clothes should be removed, and the victim should be covered with warm blankets. Unconscious victims could aspirate if fluids are given. For a conscious victim, warm nonalcoholic fluids should be provided. Rapid rewarming can cause cardiac arrest. Rubbing frozen tissues can cause additional tissue damage. The victim needs medical help as soon as possible.