Critical Care: BLS/Cardiopulmonary Resuscitation

When performing cardiopulmonary resuscitation (CPR), the nurse should deliver how many breaths per minute to an adult client?

✅10 📑 Rationale: During CPR, the nurse would deliver 10 breaths per minute to an adult client.

The nurse notes that an 8-year-old child is choking. As the nurse rushes to aid the conscious and alert child, the nurse plans to place the hands between which landmarks to remove the foreign body?

✅The umbilicus and xiphoid process 📑 Rationale: To perform abdominal thrusts, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The thumb side of one fist is placed against the victim'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.

The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. All options must be used.

1.Determine unconsciousness by shaking the client and asking, "Are you OK?" 2. Perform chest compressions. 3. Open the client's airway. 4.Initiate breathing. 📑 Rationale: The sequence for basic CPR for primary health care providers follows the CAB—compressions, airway, breathing—procedure. After determining unconsciousness, compressions are started.

An automatic external defibrillator (AED) is available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm by doing which?

✅Applying the adhesive patch electrodes to the skin and moving away from the client. 📑 Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse orders anyone near the client to move away and not touch the client (to eliminate movement artifact). The defibrillator analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate.

The nurse witnesses a person starting to choke in the hospital cafeteria. Before performing abdominal thrusts, which action should the nurse perform? Begin rescue breathing. Look for pallor or cyanosis. Ask the client, "Are you choking?" Place the arms around the victim's waist.

✅Ask the client, "Are you choking?" 📑 Rationale: As a first step in performing abdominal thrusts, the nurse verifies that the client cannot breathe. This is done by asking the client, "Are you choking?" If the client nods, the nurse proceeds. The arms are encircled about the waist once the nurse is certain that the client is actually choking. Option 1 is done only after successful abdominal thrusts if the client is not breathing. Option 2 is incorrect.

The nurse arrives at the scene of a code and begins to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. The nurse knows that interruptions in performing chest compressions should be limited to less than how many seconds? 5 10 15 20

✅10 📑 Rationale: When performing CPR, interruptions should be limited to less than 10 seconds (i.e., rotating compressors, delivering shock, pulse check). Five seconds would not give adequate time to deliver a shock and take pulse checks. The other options are too lengthy to limit chest compressions.

The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin?

✅100 times per minute 📑 Rationale: In an infant, the rate of chest compressions is at least 100 per minute

The nurse should use which best method to open the airway of a victim who has a suspected neck injury?

✅Jaw thrust maneuver. 📑 Rationale: Whenever a neck injury is suspected, it is best to use the jaw thrust maneuver during basic life support (BLS) to open the airway. If this is not possible then the head tilt-chin lift is acceptable. The neutral or sniffing position is used to open the airway in an infant. There is no such position as head tilt-jaw thrust.

The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions?

✅On the lower half of the sternum. 📑 Rationale: Chest compressions are done by placing the hands on the lower half of the sternum.

An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which action next?

✅Orders personnel away from the client, charges the machine, and depresses the discharge buttons. 📑 Rationale: If the AED advises to defibrillate, the rescuer orders all personnel 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 (up to three consecutive attempts at 200, 300, and 360 joules) is similar to that of conventional defibrillation.

A licensed practical nurse (LPN) is a certified basic life support (BLS) instructor. The LPN is conducting a BLS recertification class and is discussing automated external defibrillation. A member of the class asks the LPN to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN tells the class that the conductive gel pads are placed in which location on the client's chest?

✅Under the right clavicle and to the left of the precordium. 📑 Rationale: In defibrillation, one gel pad is placed on the upper right chest next to the sternum and below the clavicle and the other to the left of the precordium. The electrode paddles are placed over the pads for defibrillation with firm pressure.

The nurse is conducting a teaching session on basic life support (BLS) for nursing students. Which statement made by a nursing student indicates a need for further teaching? "I will be sure to provide effective compressions and avoid excessive ventilation." "I will be sure to allow for full chest recoil when performing chest compressions." "I will remember the algorithm airway, breathing, and compressions to guide my actions when providing BLS." "I will remember that I should perform cardiopulmonary resuscitation (CPR) if the client is not breathing or is gasping."

✅"I will remember the algorithm airway, breathing, and compressions to guide my actions when providing BLS." 📑 Rationale: The American Heart Association set forth new guidelines for BLS for the primary health care provider. Among these changes is a new emphasis on the algorithm CAB—compressions, airway, breathing—rather than the ABCs—airway, breathing, and circulation. Another new emphasis is on effective compressions and the avoidance of excessive ventilation. In addition, CPR should be performed if the client is not breathing or is gasping. The nursing student should be taught to allow for full chest recoil when performing chest compressions in order for the compressions to be effective.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority?

✅Connecting the resuscitation bag to the oxygen outlet. 📑 Rationale: The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower initial priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support and may be prescribed. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first?

✅Call for help and initiate cardiopulmonary resuscitation (CPR). 📑 Rationale: When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client.

The nurse employed in the pediatric unit working on the 11:00 pm to 7:00 am shift finds an infant unresponsive and without respiration or a pulse. The nurse plans to deliver chest compressions at which rate? 60 times per minute 80 times per minute 100 times per minute 140 times per minute

✅100 times per minute. 📑 Rationale: In an infant, the rate of chest compressions is at least 100 per minute. Options 1 and 2 are rates too slow to sustain oxygenation. Option 4 is a rate too fast to allow effective chest compressions.

The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse tells the group that when performing chest compressions on adults, the sternum should be depressed to at least which depth? 1 inch 2 inches One third to one half the depth of the chest Deep enough to make a hand impression

✅2 inches 📑 Rationale: When performing CPR on adults, the sternum is depressed at least 2 inches. The remaining depths of compression could be ineffective or harmful.

The nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac arrest victim. Which is the proper compression-to-ventilation ratio for one-person CPR?

✅30:2 📑 Rationale: Current cardiopulmonary resuscitation guidelines based on evidence-based practice for one-person cardiopulmonary resuscitation recommend a 30 compression:2 respiration ratio.

To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?

✅Applying the adhesive patch electrodes to the skin and moving away from the client. 📑 Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.