Quiz 78: Emergency Measure for Life Support
Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition
Instructor Verified Answers Included
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1. The nurse is providing cardiopulmonary resuscitation (CPR) to an unresponsive patient according to the 2010 American Heart Association (AHA) resuscitation guidelines. The nurse is performing chest compressions correctly when she performs them at which rate?
a. 60 to 80 per minute
b. 120 per minute
c. 100 per minute
d. 40 to 60 per minute
2. The nurse is working in the emergency department when an 8-year-old patient is brought in with respiratory distress. The nurse is preparing to insert an oral airway. Which of the following is the appropriate size for this patient?
a. Size 1
b. Size 2
c. Size 3
d. Size 7
3. While measuring an oral airway for proper fit, the nurse places the airway so that the flange is held parallel to the front teeth with the airway against the patient’s cheek. Where is the end of the curve?
a. At the angle of the jaw
b. Above the ear
c. To the level of the nose
d. Upside down
4. Which sign or symptom of airway compromise may require insertion of an oral airway?
a. Ability of the patient to speak
b. Ability of the patient to cough forcefully
c. Presence of wheezing between coughs
d. Presence of gurgling with the respiratory cycle
5. The nurse is preparing to insert an oral airway in a patient who is exhibiting signs of potential respiratory distress. The nurse knows that candidates for oral airway placement are those:
a. with oral trauma.
b. with loose teeth.
c. who are unconscious.
d. who have had recent oral surgery.
6. Which of the following is the appropriate technique for a nurse to implement when inserting an oral airway?
a. Insert the airway with the curved end up, then rotate it 180 degrees at the back of the throat.
b. Insert the airway with the curved end down along the curve of the tongue.
c. Use a tongue blade to insert and push the airway into position.
d. Insert the airway sideways, then rotate it with the curved end up.
7. The nurse is providing an educational seminar to a group of nursing students on the advantages of using an automated external defibrillator (AED). She knows that her teaching has been effective when the students reply:
a. “Health care providers do not need to learn CPR to use the AED.”
b. “The health care provider is given a printout of the rhythm change.”
c. “The health care provider can safely use both CPR skills and AED skills.”
d. “The health care provider can adjust the level of shock administered.”
8. The nurse finds a patient lying on the bathroom floor. The patient is unresponsive and has a pulse but is not breathing. What is the nurse’s first action?
a. Give two breaths using mouth-to-mouth without a barrier device.
b. Give two breaths using mouth-to-mouth without a barrier device and watch for chest movement.
c. Give two breaths using a bag-mask device.
d. Start chest compressions until an automated external defibrillator (AED) is available.
9. The patient is brought to the emergency department after a motor vehicle accident. The patient has head and neck trauma and has stopped breathing. What should the nurse do?
a. Open the airway using the head tilt–chin lift method.
b. Open the airway using the jaw-thrust method.
c. Give two breaths using mouth-to-mouth and a barrier device.
d. Give two breaths using a bag-mask device.
10. During the secondary survey of the code event, the nurse realizes that the patient is not breathing on his own. What should the nurse do next?
a. Immediately intubate the patient.
b. Have a laryngoscope handle and curved blades available.
c. Ensure that the light source on the laryngoscope is functional.
d. Have a laryngoscope handle and straight blades available.
11. The nurse is performing cardiopulmonary resuscitation (CPR) on an adult patient who has an endotracheal tube in place. At what rate does the nurse, who is alone, administer breaths?
a. 8 per minute
b. 12 per minute
c. 20 per minute
d. 24 per minute
12. The nurse enters her patient’s room to find him unresponsive. She begins cardiopulmonary resuscitation (CPR) according to protocol. How deep should the nurse do chest compressions in this pulseless adult?
a. 1 to inches in depth
b. to 3 inches in depth
c. to 1 inch in depth
d. to 2 inches in depth
13. The nurse observes a person collapse and stop breathing. The nurse would establish an airway by:
a. inserting an endotracheal tube.
b. inserting a finger to pull the tongue forward.
c. using the head tilt–chin lift maneuver.
d. using a modified jaw-thrust maneuver.
14. The nurse is performing cardiac compressions on a 4-year-old child with the assistance of another nurse. The nurses would deliver breaths and compressions at a ratio of _____ compressions for _____ breaths.
a. 30; 2
b. 5; 1
c. 15; 2
d. 5; 2
15. When applying an automated external defibrillator, the nurse would:
a. connect the cable to the machine, apply the pads, and turn on the power.
b. turn on the power, apply the pads, and connect the cable.
c. turn on the power, connect the cable, and apply the pads.
d. connect the cable, turn on the power, and apply the pads.
16. When using an automated external defibrillator, it is important for the nurse to ensure that no one is touching the patient:
a. after connecting the cable to the machine.
b. when the machine is plugged in.
c. while the pads are applied.
d. while the machine analyzes the rhythm.
17. The nurse sees on the cardiorespiratory monitor that the patient’s cardiac rhythm has changed from normal sinus rhythm to ventricular fibrillation. The nurse knows that the most effective means of converting this rhythm is:
a. cardiopulmonary resuscitation (CPR).
d. precordial thump.
18. The nurse would call the code team for which of the following patients?
a. A patient with blood pressure of 60/28 mm Hg
b. A patient experiencing severe dyspnea secondary to asthma
c. A patient in atrial fibrillation
d. An unconscious patient in ventricular tachycardia
19. The nurse enters the patient’s room and finds that the patient is not breathing and has no pulse. The patient does not have a do-not-resuscitate order. What would the nurse’s most immediate action be?
a. Call the cardiac/respiratory arrest team.
b. Begin cardiopulmonary resuscitation (CPR).
c. Call a co-worker for help.
d. Get the crash cart.
20. For which of the following patients would the nurse request the rapid response team’s immediate intervention?
a. A patient complaining of severe postoperative incisional pain
b. A patient with no pulse who is not breathing
c. A patient complaining of chest pain, hypotension, and shortness of breath
d. A patient with blood pressure of 164/96 mm Hg
21. A patient has been found with no pulse or respirations. The cardiopulmonary arrest team has been called. What should the nurse do while awaiting the team’s arrival?
a. Gather the patient’s medical record and medication administration record.
b. Obtain the crash cart.
c. Notify the patient’s primary care provider.
d. Perform cardiopulmonary resuscitation (CPR).
1. The nurse in the intensive care unit (ICU) is caring for a newly admitted patient with chest pain. She is aware that dysrhythmia may be caused by which of the following? (Select all that apply.)
a. Electrolyte disturbances
b. Heart damage
d. Respiratory arrest
2. The nurse walks into her patient’s room to find him unresponsive. She begins cardiopulmonary resuscitation (CPR), knowing that during a “code” situation, chest compressions should be interrupted for which of the following situations? (Select all that apply.)
b. Pulse checks
3. The nurse is caring for an unconscious patient who has an oral airway in place, and who has copious amounts of oral secretions. What may the nurse have to do while caring for this patient? (Select all that apply.)
a. Cleanse the mouth frequently using lemon glycerin swabs.
b. Replace or clean the oral airway.
c. Suction the oral cavity frequently.
d. Keep the airway in place for extended periods.
4. What is the nurse’s responsibility for the patient after he has been intubated during a code event? (Select all that apply.)
a. Ventilate using a bag-mask device at a rate of 22 breaths per minute.
b. Auscultate the epigastric area.
c. Auscultate both lungs.
d. Call for a chest radiograph.
1. Many cardiac arrests are caused by irregular heart rhythms known as ________________.
2. In the event of cardiopulmonary arrest, all patients receive cardiopulmonary resuscitation (CPR) unless otherwise indicated in the patient’s _________________.
3. A semicircular, minimally flexible, curved piece of hard plastic that is inserted into the mouth so it extends from just outside the lips to the pharynx is known as an ____________.
4. The most common cause of airway obstruction in an unresponsive patient is the __________.