MEDSURG II: Basic Life Support

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2. Nonarousable, sinus rhythm, BP 88/60 mm Hg 3. Arousable, marked bradycardia, BP 86/54 mm Hg 4. Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

Answer: 1 Rationale: After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.

The nurse is initiating 1-rescuer cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions? 1. On the lower half of the sternum 2. On the upper half of the sternum 3. On the lower third of the sternum 4. On the upper third of the sternum

Answer: 1 Rationale: Chest locations are found by placing the hands on the lower half of the sternum. To locate this area, find the notch where the rib margin meets the sternum, and place the middle finger on this notch and the index finger next to it. Next, place the heel of the opposite hand on the lower half of the sternum, close to the index finger. Remove the first hand, place it on top of the hand on the sternum, and begin chest compressions. Chest compressions will not be as effective with the hand placements described in the remaining options.

To perform cardiopulmonary resuscitation (CPR), the nurse should use the method pictured to open the airway in which situation? Refer to figure. 1. If neck trauma is suspected 2. In all situations requiring CPR 3. If the client has a history of seizures 4. If the client has a history of headaches

Answer: 1 Rationale: The jaw thrust without the head tilt maneuver is used when head or neck trauma is suspected. This maneuver opens the airway while maintaining proper head and neck alignment, reducing the risk of further damage to the neck. Options 2, 3, and 4 are incorrect. In addition, it is unlikely that the nurse would be able to obtain data about the client's history.

The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 1. Use of the head tilt-chin lift 2. Checking the scene for safety 3. Use of the jaw thrust maneuver 4. Moving the client away from a busy traffic road

Answer: 1 Rationale: Whenever a neck injury is suspected, the jaw thrust maneuver should be used during basic life support (BLS) to open the airway. The head tilt-chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. The scene should be checked for safety, and the client should be moved away from a busy traffic road in order to ensure safety.

The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community members. The nurse tells the group that when chest compressions are performed on infants, the sternum should be depressed how far? 1. At least 2 inches (5 cm) 2. About 1½ inches (4 cm) 3. At least one half the depth of the chest 4. Deep enough to make a finger impression

Answer: 2 Rationale: According to the American Heart Association's 2015 guidelines, when CPR is performed on infants, the sternum should be depressed at least one third the depth of chest, which is about 1½ inches or 4 cm. The remaining options are incorrect.

The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next? 1. Prepare epinephrine. 2. Charge the defibrillator. 3. Check the client's heart rhythm. 4. Pause CPR for 20 seconds and reassess.

Answer: 2 Rationale: For witnessed adult cardiac arrest when a defibrillator is immediately available, it is reasonable that the defibrillator be used as soon as possible. For adults with unmonitored cardiac arrest or for whom a defibrillator is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use. After completing 5 cycles of compressions and ventilations, the nurse should reassess the client by checking the heart rhythm. Defibrillation may be warranted depending on the assessed rhythm. Epinephrine may be prepared depending on the rhythm, but this would be prescribed by a health care provider (HCP). Chest compressions should not be interrupted for more than 10 seconds.

The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? 1. Hold the defibrillator paddles firmly against the chest. 2. Apply adhesive patch electrodes to the chest and move away from the client. 3. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device. 4. Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm.

Answer: 2 Rationale: The nurse or rescuer puts two adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse stops CPR and requests that anyone near the client move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates whether defibrillation is necessary.

The nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor. The nurse should immediately take which action? Refer to Figure. 1.Take the client's blood pressure. 2.Initiate cardiopulmonary resuscitation (CPR). 3.Place a nitroglycerin tablet under the client's tongue. 4.Continue to monitor the client for 1 minute and then contact the health care provider (HCP).

Answer: 2 Rationale: This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The HCP or an advanced cardiac life support-qualified nurse must immediately defibrillate the client. If a defibrillator is not readily available, CPR must be initiated until the defibrillator arrives. The remaining options are incorrect; these are not immediate actions and would delay life-saving treatment.

The nurse notes that a 14-year-old child is choking but is awake and alert at this time. The nurse rushes to perform the abdominal thrust maneuver. The child becomes unconscious. What procedure should the nurse perform next? 1. Perform a finger sweep. 2. Start chest compressions. 3. Attempt rescue breathing. 4. Ask the parent what happened.

Answer: 2 Rationale: To perform the abdominal thrust maneuver for a conscious child, the rescuer stands or kneels behind the child and places the arms directly under the child's axillae and then around the child. The thumb side of 1 fist is placed against the child's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand, and upward thrusts are delivered. If the child becomes unconscious, the nurse should start cardiopulmonary resuscitation, first beginning compressions. Performing a blind finger sweep is not recommended. If the object can be visualized and is retrievable, it is acceptable to attempt to remove the object. Rescue breathing is not appropriate at this time but may be necessary later. It will be necessary at some point to determine what happened, but this would not be the nurse's next action.

An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action? 1. The ratio of compressions to ventilations is 30:2. 2. The carotid pulse is palpable with each compression. 3. Respirations are given at a rate of 10 breaths per minute. 4. The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5 cm).

Answer: 2 Rationale: With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital. Assessment of the carotid pulse during CPR is the most accurate way to assess the effectiveness of CPR. Correct procedure for CPR in an adult includes a compression-to-ventilation ratio of 30:2. With adults, compressions are performed at a depth of at least 2 inches (5 cm). The 30:2 compression-to-ventilation ratio yields an effective rate of 10 breaths per minute.

The nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the pulse point to use when determining pulselessness on an infant. Which response by the nurse identifies the most appropriate pulse point? 1. Radial 2. Carotid 3. Brachial 4. Popliteal

Answer: 3 Rationale: When assessing a pulse in an infant (younger than 1 year), the pulse should be checked at the brachial artery. This is because the relatively short, fat neck of an infant makes palpation of the carotid artery difficult. The pulses in the remaining options are also difficult to locate and palpate in an infant.

The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions in a pregnant woman. The nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus? 1. Perform the chest compressions directly over the umbilicus. 2. Turn the pregnant client on her side and perform back thrusts. 3. Maintain manual left uterine displacement during compressions. 4. Perform chest thrusts midway between the umbilicus and the pubic bone.

Answer: 3 Rationale: According to the American Heart Association's current guidelines for performing cardiopulmonary resuscitation (CPR), recognition of the critical importance of high-quality CPR and the incompatibility of the lateral tilt with high-quality CPR has prompted the elimination of the recommendation for using the lateral tilt and the strengthening of the recommendation for lateral uterine displacement. Priorities for the pregnant woman in cardiac arrest are provision of high-quality CPR and relief of aortocaval compression. If the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compressions.

Cardiopulmonary resuscitation (CPR) is immediately initiated on a client who is unconscious and has no pulse. A monitor is attached and it is determined that the rhythm is shockable, and defibrillation with 1 shock is delivered. Which action should the nurse plan to take next? 1. Defibrillate 1 more time, and then terminate the resuscitation effort. 2. Administer a bolus of fluid intravenously, and resume defibrillation attempts. 3. Perform CPR for 5 cycles, and then defibrillate again if the rhythm is shockable. 4. Perform CPR for 1 minute, assess, and then defibrillate up to 3 more times.

Answer: 3 Rationale: If a client is unconscious and has no pulse, the nurse would shout for help (activate emergency response) and immediately initiate CPR. If the rhythm is shockable, a shock is delivered and then CPR is delivered for 5 cycles. This pattern is repeated 2 more times if the rhythm remains shockable. Treatment with medications is also done during this time to reverse the cause of the ventricular fibrillation. Each of the other options is incorrect.

The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure? 1. Radial artery 2. Carotid artery 3. Brachial artery 4. Popliteal artery

Answer: 3 Rationale: To assess a pulse in an infant (younger than 1 year), the pulse is checked at the brachial or femoral artery. The infant's relatively short, fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant.

The nurse is teaching chest compressions for cardiopulmonary resuscitation (CPR) to a group of lay clients. Which behavior by one of the participants indicates a need for further teaching? 1. Keeping the shoulders directly over the hands 2. Straightening the arms and locking the elbows 3. Letting the right and left fingers rest on the chest 4. Performing compressions on the lower half of the sternum

Answer: 3 Rationale: To maximize the effectiveness of chest compressions, the rescuer avoids letting the fingers rest on the chest. This also helps prevent accidental injury to internal organs. The actions listed in the other options are all part of correct CPR procedures.

The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. Refer to Figure. 1. Prepare for cardioversion. 2. Prepare to administer digoxin 3. Prepare to administer amiodarone. 4. Prepare to administer epinephrine. 5. Provide cardiopulmonary resuscitation (CPR).

Answer: 3,4,5 Rationale: Pulseless ventricular tachycardia is treated the same way as ventricular fibrillation with measures that include defibrillation, CPR and medication therapy, with agents such as epinephrine and amiodarone and others.

The nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. What is the nurse's next action after calling for help? 1. Check for carotid pulse. 2. Call anesthesia for intubation. 3. Begin rescue breathing with head tilt-chin lift. 4. Perform compressions at 100 to 120 times per minute.

Answer: 4 Rationale: After pressing the emergency response button in the room, the nurse should begin cardiopulmonary resuscitation (CPR) on the infant, starting with chest compressions. The rate of chest compressions is 100 to 120 times per minute. The brachial pulse is assessed on infants; the carotid pulse is difficult to palpate due to their short, thick necks. When a cardiopulmonary arrest alert is called, an experienced staff member with intubation skills is usually included on the response team. Compressions are started before rescue breathing.

External public access defibrillator (PAD) interprets that the rhythm of a pulseless victim is ventricular fibrillation and advises defibrillation. Which action should the rescuer take next? 1. Administer rescue breathing during the defibrillation. 2. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating. 3. Charge the machine and immediately push the discharge buttons on the console. 4. Order people away from the client, charge the machine, and depress the discharge buttons.

Answer: 4 Rationale: If the victim is in ventricular fibrillation, defibrillation is necessary. If the PAD advises to defibrillate, the rescuer orders all people away from the client, charges the machine, and pushes both of the discharge buttons on the console at the same time. The charge is delivered through the patch electrodes, so this method is known as "hands off" defibrillation, which is safer for the rescuer. The sequence of charges is similar to that of conventional defibrillation.

To perform defibrillation, the defibrillator pads should be placed in which areas of the client's chest? 1. Behind the right and left shoulders in the scapular area 2. 1 inch (2.5 cm) below the sternum and 4 inches (10 cm) to the left of the sternum 3. 1 inch (2.5 cm) below the umbilicus and 2 inches (5 cm) to the right of the left nipple 4. To the right of the sternum just below the clavicle and to the left side, just below and to the left of the pectoral muscle

Answer: 4 Rationale: The anterior-apex placement works well for defibrillation and cardioversion, as well as for monitoring an electrocardiogram. In this placement, the anterior pad is placed on the right, below the clavicle. The other is applied to the left side of the client, just below and to the left of the pectoral muscle.

A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1. 50 J 2. 120 J 3. 200 J 4. 360 J

Answer: 4 Rationale: The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.

A client is brought into the emergency department in ventricular fibrillation (VF). The nurse prepares to defibrillate by placing defibrillation pads on which part of the chest? 1. The upper and lower halves of the sternum 2. Parallel between the umbilicus and the right nipple 3. The right shoulder and the back of the left shoulder 4. To the right of the sternum and to the left of the precordium

Answer: 4 Rationale: The nurse would place 1 gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. The nurse would then place the electrode paddles over the pads. The remaining options identify incorrect positions.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1. Ensure that the client has been intubated. 2. Set the defibrillator to the "synchronize" mode. 3. Administer an amiodarone bolus intravenously. 4. Confirm that the rhythm is actually ventricular fibrillation.

Answer: 4 Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.

The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first? 1. Heart rate 2. Blood pressure 3. Respiratory rate 4. Check responsiveness

Answer: 4 Rationale: VT is associated with a significant decrease in cardiac output. Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac output. Therefore, the first action is to determine responsiveness of the client. Then the nurse should check the client's pulse to determine the next treatment strategy.

The nurse is teaching adult cardiopulmonary resuscitation (CPR) guidelines to a group of laypeople. The nurse observes the group correctly demonstrate 2-rescuer CPR when which ratio of compressions to ventilations is performed on the mannequin? 1. 10:1 2. 15:2 3. 20:1 4. 30:2

Answer: 4 Rationale: When performing CPR on adults, the ratio of chest compressions to breaths should be 30:2 for both 1-rescuer and 2-rescuer CPR. The ratio of 15:2 is used for children and infants during 2-rescuer CPR.

In order of priority, how should the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they should be performed. All options must be used. 1.Open the airway. 2.Attempt ventilation. 3.Assess unconsciousness. 4.Perform abdominal thrusts. 5.Look in the mouth and remove the object blocking the airway, if seen.

In order of priority: 3,1,5,2,4 Rationale: For health care providers (HCPs) such as the nurse, the sequence for removing a foreign body airway obstruction in an adult is as follows. After determining unconsciousness, the airway is opened and the rescuer looks into the mouth of the victim and removes the object blocking the airway, if it is seen. Next, the HCP attempts to ventilate the victim. If unsuccessful, the victim's head is repositioned and ventilation is reattempted. Five abdominal thrusts are then delivered. The sequence is repeated until successful.