NCLEX PN - Emergency Situations / BLS and CPR
the nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. the nurse immediately notifies the RN and then performs which action? a) checks the vital signs b) begins fundal massage c) encourages ambulation d) encourages the client to drink fluids
a) checks the vital signs rationale symptoms of hypovolemia include, cool, clammy, and pale skin; feelings of anxiety and restlessness; and thirst. the nurse would check the vital signs. the nurse would not ambulate the client or encourage fluids until specific prescriptions are given to do so. there is no information in the question to indicate the need for fundal massage.
the nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. the client suddenly complains of chest pain and dyspnea. the nurse should initially check which item? a) vital signs b) fundal height c) presence of calf pain d) LOC
a) vital signs rationale pulmonary embolism is a complication of thrombophlebitis. changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. fundal height is unrelated to the subject of the question. calf pain is an indicator of thrombophlebitis. level of consciousness may change as the condition worsens; worsening would indicate hypoxia.
the nurse is performing CPR on an adult. the nurse should deliver how many breaths per minute to the client? a) 6 b) 10 c) 18 d) 20
b) 10 rationale each rescue breath is delivered over 1 second at a rate of 1 breath every 8 seconds ( 8 to 10 ventilations per minute) the other options are incorrect
the nurse is assigned to assist with caring for a client who is at risk for eclampsia. if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? a) administer oxygen by face mask b) clear and maintain an open airway c) check the blood pressure and the fetal heart tones d) prepare for the administration of IV magnesium sulfate
b) clear and maintain an open airway rationale the first actions are to maintain an open airway and to prevent injuries to the client. the client should be turned to the side and monitored for airway compromise. the other options may be components of care, but they are not the first actions.
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 scares of 1 and 4. when planning for the admission of this infant which is the nurse's highest priority? a) turning on the apnea and cardiorespiratory monitor b) connecting the resuscitation bag to the oxygen outlet c) setting up the IV line with 5% dextrose in water d) setting the radiant warmer control temperature at 36.5 C (97.6 F)
b) 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 IV 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
a woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. the fetal heart rate between contractions is 100 bpm. on the basis of these findings which is the priority nursing action? a) monitor the maternal vital signs b) notify the RN immediately c) continue monitoring labor and fetal heart rate d) encourage relaxation and breathing techniques between contractions
b) notify the RN immediately rationale fetal bradycardia between contractions may indicate the need for immediate medical management. the nurse would immediately contact the RN, who would then contact the HCP. the other others will delay necessary and immediate interventions
the nurse is performing CPR on an infant. when performing chest compressions, which is the compression rate for an infant? a) 60 times per minute b) 80 times per minute c) 100 times per minute d) 160 times per minute
c) 100 times per minute rationale for an infant, the rate of chest compressions is at least 100 per minute. the first two options identify rates that are too low, and the last option identifies a rate that is too high
the nurse is performing CPR on an adult client. how far should the sternum be depressed in an adult client for effective chest compressions? a) 1 inch b) 3/4 inch c) 2 inches d) 3 inches
c) 2 inches rationale when performing CPR on an adult client, the sternum is depressed 2 inches. the first two options identify compression depths that would be ineffective for an adult, and the last option identifies a depth that could cause injury to the client
which is the most appropriate location for assessing the pulse of an infant who is less than 1 year old? a) radial b) carotid c) brachial d) popliteal
c) brachial rationale to assess a pulse in an infant (a child younger than 1 year old), the pulse is checked at the brachial artery (femoral artery can also be used) 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
a mother calls a neighborhood nurse and tells the nurse that her 3 year old child had just ingested liquid furniture polish. which action should the nurse instruct the mother to take first? a) induce vomiting b) call an ambulance c) call the poison control center d) bring the child to the emergency department
c) call the poison control center rationale if a poisoning occurs, the poison control center should be contacted immediately. vomiting should not be induced without instructions to do so if the victim is unconscious or the substance ingested is a strong corrosive or petroleum product. bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. the poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.
the nurse witnesses a neighbor's husband sustain a fall from the roof of his house. the nurse rushes to the victim and determines the need to open the airway. the nurse opens the airway in this victim with the use of which method? a) flexed position b) head tilt-chin left c) jaw thrust maneuver d) modified head tilt-chin lift
c) jaw thrust maneuver rationale if a neck injury is suspected, the jaw thrust maneuver is used to open the airway. the head tilt-chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. a flexed position is an inappropriate position for opening the airway
the nurse assists in planning care for a child who sustained a burn injury. the nurse plans care based on which accurate statement? a) scarring is not as severe in a child as in an adult b) children are at a lower risk of infection than adults because of their strong immune systems c) lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner d) infants and children are at decreased risk for protein and calorie deficiency because they have smaller muscle mass and less body fats than adults.
c) lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner rationale lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. scarring is more severe in a child; additionally, disturbed body image will be a distinct issue for a child or adolescent, especially as growth continues. an immature immune system presents an increased risk for infection for infants and young children. infants and children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.
the nurse on the day shift 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. the next nursing action is which? a) deliver breaths b) give the client oxygen c) start chest compressions d) ventilate with a mouth-to-mask device
c) start chest compression rationale the nurse would follow CAB: compressions, airway and breathing. therefore, the next nursing action would be to start chest compressions.
the nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. the nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. the client suddenly becomes restless, and his color is becoming dusky. the nurse should interpret this data as indicating which? a) the client is hypotensive b) pain is present from the burn injury c) the burn has probably caused laryngeal edema, which has occluded the airway d) the client is afraid and is having a panic attack as a result of the unfamiliar surroundings
c) the burn has probably caused laryngeal edema, which has occluded the airway rationale the client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. additionally, one of the cardinal signs of hypoxia is restlessness.
the nurse is assisting with caring for a client with abruptio placenta. while caring for the client, the nurse notes that the client begins to develop signs of shock. the nurse should take which action first? a) monitor urinary output b) monitor the maternal pulse c) turn the client on her side d) monitor the maternal blood pressure
c) turn the client on her side rationale with a pregnant client who is in shock, the nurse would want to increase perfusion to the placenta. a simple way to do this that requires no equipment is to turn the mother on her side. this would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. the nurse would immediately contact the RN, who would then contact the HCP. the other options would follow quickly.
the client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. which should the nurse anticipate as being prescribed for the client? a) oxygen via nasal cannula at 10 L b) oxygen via nasal cannula at 15 L c) 100% oxygen via an aerosol mask d) 100% oxygen via a tight-fitting, nonrebreather face mask
d) 100% oxygen via a tight-fitting nonrebreather mask rationale if an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. with inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations . the need for endotracheal intubation is also determined. the other options are incorrect
the nurse suspects that the client has a pulmonary embolism. which is the most important nursing action? a) monitor the vital signs b) elevate the head of the bed c) increase the IV flow rate d) administer oxygen by face mask, as prescribed
d) administer oxygen by face mask, as prescribed rationale because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. the first two options may be components of the plan of care, but they are not the most important actions. the nurse would not increase the IV rate without a prescription from the HCP to do so.
the nurse attempts to relieve an airway obstruction on a 6 year old conscious child. which location is the correct placement of the hands to perform this maneuver? a) between the groin and the abdomen b) between the umbilicus and the groin c) between the lower abdomen and the chest d) between the umbilicus and the xiphoid process
d) between the umbilicus and the xiphoid process rationale to relieve an airway obstruction in a child, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. the rescuer places the thumb side of one fist against the victim's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. the rescuer grasps the fist with the other hand and delivers up to five thrusts. one must take care not to touch the xiphoid process or the lower margins of the rib cage, because force applied to these structures may damage the internal organs. the other options are incorrect hand placements
the nurse understands that which is a correct guideline for adult CPR for a health care provider? a) one breath should be given for every 5 compressions b) two breaths should be given for every 15 compressions c) initially, two quick breaths should be given as rapidly as possible d) each rescue breath should be given over 1 second and should produce a visible chest rise
d) each rescue breath should be given over 1 second and should produce a visible chest rise rationale during adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. HCPs should employ a 30 compression-to-2 ventilation ratio for the adult victim. the other options are incorrect
the nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. how should the student describe the procedure correctly? a) place the hands in the pelvis to perform the thrusts b) perform abdominal thrusts until the object is dislodged c) perform left lateral abdominal thrusts until the object is dislodged d) place a rolled blanket under the right abdominal flank and hip area
d) place a rolled blanket under the right abdominal flank and hip area rationale to relieve an airway obstruction on an unconscious woman in an advanced stage of pregnancy, the woman is placed on her back. a wedge, such as a pillow or rolled blanket, is placed under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. the other options are incorrect and can cause harm to the woman and the fetus.
the nurse educator is teaching principles of CPR to a group of nursing students. the nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. the nurse determines that the student understands the reason if the student makes which statement? a) the object may have been swallowed b) the infant may bite down on the finger c) the mouth is too small to see the object d) the object may be forced back further into the throat
d) the object may be forced back further into the throat rationale blind finger sweeps are not recommended for infants and children because of the risk of forcing the object further down into the airway. the other options are not related directly to the subject of the question.
the nurse is caring for an infant with a diagnosis of tetralogy of Fallot. the infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. which interventions should the nurse perform? select all that apply call a code blue notify the RN place the infant in a prone position prepare to administer morphine sulfate prepare to administer IV fluids prepare to administer 100% oxygen by face mask
notify the RN // prepare to administer morphine sulfate // prepare to administer IV fluids // prepare to administer 100% oxygen by face mask rationale the child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. hypercyanotic episodes occur among infants with tetralogy of fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. if a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. the RN is notified, who will then contact the HCP. the knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. toddlers and children squat to get into this position and relieve chronic hypoxia. there is no reason to call a code blue unless respirations cease. additional interventions include administering 100% oxygen by face mask, morphine sulfate, and IV fluids as prescribed.
