Deck 30: Emergency Measures for Life Support

Question 1

An AED has been applied and a shock delivered to a patient.What action does the nurse take at this time?

A) Provide 2 minutes of cardiopulmonary resuscitation (CPR) before beginning rhythm analysis and the shock sequence again.
B) Provide three cycles of CPR before beginning rhythm analysis and the shock sequence again.
C) Move nearby furniture away from the patient.
D) Announce "clear" and perform a visual check that no one is touching the patient.

Answer 1

Provide 2 minutes of cardiopulmonary resuscitation (CPR) before beginning rhythm analysis and the shock sequence again.

Question 2

A student nurse is performing compressions on an adult.The rate of compressions drops to 90/min.What action by the faculty member is best?

A) Ask the student if he or she is too tired to continue.
B) Assess for a pulse at the femoral or carotid artery.
C) Remind the student to switch to ventilations after 2 minutes.
D) Tell the student he or she needs faster compressions.

Answer 2

Tell the student he or she needs faster compressions.

Question 3

A visitor has coded in the hospital cafeteria, and several nurses witnessed the code.What is the proper procedure for initiating use of the automatic external defibrillator (AED)?

A) Provide 5 cycles of cardiopulmonary resuscitation (CPR) before shocking.
B) Place AED pads and shock as soon as possible, if needed.
C) Insert an oropharyngeal airway before shocking.
D) Place the AED pads on either side of the chest.

Answer 3

Place AED pads and shock as soon as possible, if needed.

Question 4

A nurse is instructing staff nurses in the use of the automatic external defibrillator (AED).Which information is essential for the nurse to share with the class?

A) For children younger than 8 years old, pediatric AED pads should be used.
B) The AED takes approximately 30 seconds to analyze the cardiac rhythm.
C) The AED is used when the patient is unconscious and has no respirations.
D) The AED is placed near the patient's feet during use.

Question 5

The nurse walks into a patient's room and finds the patient on the floor with eyes closed.Which does the nurse implement first?

A) Initiate cardiac compressions.
B) Call for a code from the room.
C) Help the patient back into the bed.
D) Verify patient unresponsiveness.

Question 6

A patient is receiving targeted temperature management after cardiac arrest.What explanation of this treatment does the nurse provide the family?

A) It improves neurological outcomes after cardiac arrest.
B) It manages the fever produced by defibrillation.
C) It salvages the damaged heart muscles.
D) It keeps the fluid and electrolytes in balance.

Question 7

The nurse has just called a code and is preparing to perform cardiopulmonary resuscitation (CPR) on a child.Where does the nurse position the hands for chest compressions?

A) Puts both hands over the upper half of the child's sternum.
B) Places the heel of one hand on the lower half of the sternum.
C) Puts the heels of both hands on the lower third of the sternum.
D) Places two fingers below the left nipple line at the sternum.

Question 8

The nurse is caring for a patient receiving targeted temperature management.It has been 20 hours since the therapy was initiated.What assessment finding indicates goals are being met?

A) Patient is awake, alert, and oriented.
B) Patient's temperature is 35° C (95° F).
C) Only the patient's sodium level is abnormal.
D) The patient's oxygen saturation is 88%.

Question 9

The patient's resuscitation lasts 30 minutes.The code team leader has directed the efforts to stop.What action by the nurse is the priority?

A) Request the chaplain speak to the family.
B) Begin performing post-mortem cares.
C) Provide privacy but stay available to the family.
D) Gather funeral home information.

Question 10

On entering a patient's room, the nurse determines that the patient is unresponsive but has a pulse and is breathing.Which action does the nurse implement next?

A) Have another nurse check the carotid pulse.
B) Activate the emergency response system.
C) Perform a jaw thrust to open the airway.
D) Begin performing CPR.

Question 11

The coronary care unit is receiving four patients in the next hour.Which patient does the charge nurse anticipate will receive targeted temperature management?

A) Unwitnessed cardiac arrest, initial rhythm asystole
B) Witnessed cardiac arrest, rapid defibrillation with AED
C) Witnessed cardiac arrest, alert but amnesic for event
D) Unwitnessed cardiac arrest with multiple medical problems

Question 12

A student nurse is performing CPR on a child manikin.What action does the faculty member evaluate as effective technique?

A) Performs compressions with two fingers at the nipple line.
B) Compresses at a rate of at least 130/min.
C) Gives breaths to the intubated child every 6 seconds.
D) Continues 30:2 ratio with two rescuers.

Question 13

The patient is in cardiac arrest, and the nurse uses the automatic external defibrillator (AED).Which does the nurse implement to use the AED?

A) Places the AED next to the patient, turns on the unit, and follows the prompts.
B) Receives training in advanced cardiac life support (ACLS).
C) Applies a shock in coordination with the chest compressions.
D) Uses the automatic defibrillator instead of conventional cardiopulmonary resuscitation (CPR).

Question 14

The nurse participates in the patient's resuscitation.Which patient assessment finding does the nurse determine to be an undesirable event during cardiopulmonary resuscitation (CPR)?

A) Bruising is present over the anterior thorax.
B) The abdomen has become distended.
C) The patient has an advance directive.
D) An airway is in place without gagging.

Question 15

The nurse and a colleague begin cardiopulmonary resuscitation (CPR) on an adult patient.Which ratio of chest compressions to rescue breaths is used?

A) 5:1
B) 5:2
C) 10:1
D) 30:2

Question 16

The nurse determines that the patient had a cardiac arrest while ambulating in the hall.Which method should the nurse use to position the patient properly during cardiopulmonary resuscitation (CPR)?

A) Head tilt and right side-lying position
B) Logrolling and jaw thrust
C) Supine and head tilt
D) Jaw thrust and semi-Fowler's position

Question 17

The nurse needs to perform chest compressions for a pulseless child.Which depth does the nurse use for each chest compression?

A) One half to 1 inch in depth
B) One to 1 1/2 inches in depth
C) One half the depth of the chest
D) One third the depth of the chest

Question 18

The nurse has been performing cardiopulmonary resuscitation (CPR) on an adult.Which artery does the nurse check to evaluate the effectiveness of chest compressions?

A) Radial
B) Carotid
C) Brachial
D) Temporal

Question 19

The nurse determines that the patient is in cardiac arrest.Which does the nurse delegate to nursing assistive personnel (NAP)?

A) Deliver chest compressions.
B) Help with patient positioning as directed.
C) Inform the family about the patient.
D) Prepare emergency medications.

Question 20

The nurse is caring for four patients on the intermediate care unit and plans emergency care for the patients.Which patient is unsuitable for cardiopulmonary resuscitation (CPR)?

A) The older adult patient with end-stage lung disease
B) The patient with a valid order for a no-code status
C) The patient who doesn't speak English and cannot make his or her wishes known
D) The patient whose family does not want the patient resuscitated

Question 21

A student nurse is practicing using the AED.What actions by the student show the need for remediation? (Select all that apply.)

A) Dries wet skin before applying AED pads.
B) Uses pediatric pads on an adult if bigger ones aren't available.
C) Places pads on the back if the chest is wet.
D) Attaches the pads then turns the device on.
E) Modifies pad position for pacemakers.

Question 22

The charge nurse is assessing staff CPR skills.What actions by the staff are appropriate for infant CPR? (Select all that apply.)

A) Uses the 2-thumb encircling method with 2 rescuers.
B) Provides compressions at a rate of 140/min.
C) Inserts an appropriately sized oral airway.
D) Attaches the AED as soon as it's available.
E) Compresses the chest approximately 1".

Question 23

A student nurse is reviewing CPR guidelines with the faculty.What statements by the student indicate the need for a review? (Select all that apply.)

A) End-tidal CO₂ should be above 20, if available.
B) A size 1 or 2 oral airway fits most adults.
C) Compressions on an adult should be at least 100/min.
D) Adult-sized AED pads cannot be used on children.
E) Adult CPR uses 30 compressions followed by 2 breaths.

Question 24

The nurse in a trauma center is preparing to insert an oropharyngeal airway device.Which interventions will assist in this task? (Select all that apply.)

A) Place the patient in a prone position.
B) Hold the airway curved end up initially.
C) Use a padded tongue blade to open patient's mouth.
D) Measure the airway to obtain the right size.
E) Rotate the airway 90 degrees as it is inserted.

Question 25

The nurse is caring for a post-cardiac arrest patient who has needed an oral airway for 20 hours.What action by the nurse is most appropriate?

A) Remove the oral airway.
B) Consult the provider.
C) Replace the airway after 24 hours.
D) Document ongoing need.

Question 26

The nurse is assessing an unconscious patient for placement of an oropharyngeal airway.In addition to a present gag reflex, what other conditions would make the use of the airway contraindicated? (Select all that apply.)

A) A semi-conscious patient
B) A patient with a loose tooth
C) A patient who had facial trauma
D) A patient who has had oral surgery
E) A patient with copious secretions

Question 27

A new pediatric nurse is asking the charge nurse why an oral airway is not rotated while being inserted in pediatric patients.What response by the charge nurse is best?

A) The airways are so small, you will not be able to hold on to it.
B) Oral pharyngeal airways actually are not used in pediatric patients.
C) Rotating the airway can possibly further obstruct the child's airway.
D) You risk damaging the child's soft palate by rotating the airway.