CPR RAPID RESPONSE
3 (transcutaneous pads should be placed on the client with third-degree heart block. For a client who is symptomatic, transutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is performed for ventricular fibrillation or ventricular tachycardia with no pulse.)
Upon assessment of third degree heart block on the monitor, what should the nurse do first? 1. call a code 2. begin CPR 3. Place transcutaneous pacing pads on the client 4. prepare for defibrillation
4 (The thrusts should be delivered below the xiphoid process but above the umbilicus to minimize internal injury)
When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically: 1. above the umbilicus 2. at the level of the xiphoid process 3. over the victims midabdominal area 4. below the xiphoid process and above the umbilicus
2 (After a person is without cardiopulmonary function for 4-6 mins, permanent brain damage is almost certain. To prevent permanent brain damage it is important to begin CPR promptly after a cardiopulmonary arrest)
The rapid response team has been called to manage an unwitnessed cardiac arrest in a clients room. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is: 1. 1-2 min 2 4-6 min 3. 8-10 min 4. 12-15 min
3 (Amiodarone is used for the treatment of premature ventricular contractions; PVCs, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for pulseless dysrhythmia.)
A client is given amiodarone in the ED for dysrhythmia. Which finding indicates this drug is having the desired effect? 1 the ventricular rate is increasing 2. the absent pulse is now palpable 3. the number of PVC's is decreasing 4 The fine ventricular fibrillation changes to coarse ventricular fibrillation
4 (If the chest wall is not rising with rescue breaths, the airway should be repositioned first to ensure the airway is open. A bag mask allows for 100% O2 but is difficult to manage if there is only 1 rescuer. ideally 2 persons are used to operate the bag mask device, one to maintain the seal and the other to provide ventilations. Compressions should be maintained at 100 per min)
A client is recieving rescue breaths and the chest wall fails to rise during CPR. The rescuer should first: 1.. try using a bag mask device 2. decrease the rate of compressions 3. intubate the client 4. reposition the airway
1,2,4,5 (VS give an important initial assessment of this clients status. The client may experience burns from the patches and current used for the cardioversion. Therefore it is important to assess the skin on the chest wall for redness or burns. Because conscious sedation is used for this procedure, assess the LOC also is an important initial step. Attaching the client to cardiac monitoring is also important to assess rhythm abnormalities. There is no arterial puncture associated with this procedure.)
A client returns to the nursing unit following a successful synchronized cardioversion using transthoracic chest wall patches. The nurse should assess which when the client returns to the room? SATA 1 VS 2. skin of chest wall 3. arterial puncture site 4. LOC 5 cardiac rhythm
2 (pupillary reaction is the best indicator of whether oxygenated blood has been reaching the clients brain. Pupils that remain widely dilated and do not react to light may indicate lack of oxygenation and that serious brain damage may have occurred. The pulse may be normal, mucous membranes may still be pink, and systolic BP may be 80 or higher yet there can be inadequate oxygenation to the brain)
A client who has been given CPR is transported by ambulance to the hospital ER., where the admitting nurse quickly assesses the clients condition. The most effective way to evaluate adequate oxygenation is to determine if: 1, there is a pulse 2. pupils are reacting to light 3. mucous membranes are pink 4. systolic BP is at least 80
2 (The heimlich maneuver should be administered only to a victim who cannot make any sounds due to airway obstruction. If the victim can whisper or cough, some air exchange is occurring and the emergency medical system should be called instead of attempting the Heimlich maneuver. Cyanosis may accompany or follow choking, however the heimlich maneuver should only be initiated when the victim cannot speak)
A nurse helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: 1. starts to become cyanotic 2. can not speak due to airway obstruction 3. can only make minimal vocal noises 4. is coughing vigorously
2 (injury can result even if CPR is done properly)
During CPR for an adult, the rescuers hands should be placed two finger width above the lower end of the sternum Which organ would be most likely at risk for laceration by forceful compressions over the xiphoid process? 1. lung 2. liver 3.. stomach 4 diaphragm
1 (The exhalation phase of ventilation is passive activity that occurs during CPR as part of the normal relaxation of the victims chest. No action by the rescuer is necessary)
During rescue breathing in CPR the victim will exhale by: 1 normal relaxation of the chest 2. gentle pressure of the rescuers hand on the upper chest 3. the pressure of cardiac compressions 4. turning the head to the side
2 (The priority action is to assess the client and determine whether the rhythm is life threatening. More information, including VS, should be obtained, and the nurse should notify the HCP. A bolus of lidocaine may be prescribed to treat this arrhythmia. This is not a code type situation unless the client has been determined to be in a life threatening situation)
The monitor tech informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first? 1. activate the rapid response team 2. assess the clients orientation and VS 3 call the HCP 4. administer a bolus dose lidocaine
2 (The rapid response team should be called immed to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. IF the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided)
The nurse is caring for a client who has become unresponsive, the BP is 80/40 and SpO2 is 90% on 50% face mask. The nurse should: 1 begin chest compressions 2. call the rapid response team 3. remove the family from the room 4 ventilate the client with a bag mask device
3 (This ECG strip indicates the client has ventricular tachycardia. The nurse should first check the client for the presence of a pulse. The presence of a pulse determines the treatment for ventricular tachycardia. It is also important to assess the clients HR and LOC. Cardioversion may be used to treat hemodynamic unstable tachycardias. Assessment of instability is required before cardioversion. It is not appropriate to begin CPR unless the pulse is absent. Defibrillation is used to treat ventricular fibrillation, or pulseless ventricular tachycardia.)
The nurse observes the cardiac rhythm for a client who is being admitted with a myocardial infarction What should the nurse do first? 1. prepare for immediate cardioversion 2. begin CPR 3. check for a pulse 4. prepare for immediate defibrillation
4 (An adults sternum must be depressed 2 inches (5cm) with each compression to ensure adequate heart compression)
When performing external chest compressions on an adult during CPR, the rescuer should depress the sternum: 1. 0.5 inch 2. 1 inch 3. 1.5 inch 4. 2 inches
