Care of Clients Part 1

1. A client is brought to the emergency department awake and alert following a fall from a ladder from a height of 4.6 meters (15 ft). During an initial assessment, the client becomes unresponsive and stops breathing. Which method should the nurse use to open the airway? A. Head tilt–chin lift B. Jaw thrust C. Tongue–jaw lift D. None; client needs emergency intubation To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options B and D. If your answer is letter B, then you are correct. The jaw-thrust maneuver is used whenever head or cervical spine injury is suspected to avoid causing further physiological damage. The head tilt–chin lift method is the standard method for opening the airway when there is no suspected cervical spine injury. The tongue–jaw lift aids in visualizing foreign bodies in the airway. The client does not need emergency intubation. 2. The nurse has begun cardiopulmonary resuscitation (CPR) on a 5-year-old child. The nurse times the rate of ventilation to achieve up to how many breaths per minute? A. 20 B. 25 C. 30 D. 35 To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options A and C. If your answer is letter A, then you are correct. The proper ventilation rate for a child or infant is 12–20 breaths per minute, which is the same as delivering one breath every 3–5 seconds. The correct answer is 20 based on the words up to. 3. A nurse has begun to resuscitate a 10-month-old infant. In what location would the nurse check the infant’s pulse? A. Brachial B. Radial C. Carotid D. Temporal To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options A and C. If your answer is letter A, then you are correct. The brachial artery is the correct location for determining whether an infant under 1 year of age has a pulse. The radial artery would not generate enough pulsation in an infant to be reliable and is also more difficult to palpate. The carotid pulse is not as easily located in an infant with a small neck and neck folds. The temporal pulse is not used in CPR for an individual of any age. 4. The nurse on a surgical nursing unit has just called a code blue using the telephone in the room of an unresponsive adult client who had abdominal surgery. Which action would be appropriate during initiation of CPR? A. Open the airway using the jaw-thrust method. B. Deliver one deep breath before checking for a pulse. C. Depress the sternum at least 5 cm (2 inches.) during cardiac compressions. D. Reevaluate status every 3 to 5 minutes until the code team arrives. To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options C and D. If your answer is letter C, then you are correct. In an adult, the sternum should be depressed during CPR to a depth of at least 5 cm (2 inches.). The head tilt–chin lift method of opening the airway is used for the client who has no head or neck injury. After determining unresponsiveness while simultaneously checking quickly for breathing, the nurse begins chest compressions. The nurse reevaluates the client’s status after approximately 2 minutes. 5. The nurse who is doing the documentation during a code blue on an adult client observes an unlicensed assistive person (UAP) doing CPR. The nurse concludes the UAP is using correct procedure after noting that the UAP is depressing the sternum at least how many inches? A. 1 B. 2 C. 3 D. 4 To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options B and D. If your answer is letter B, then you are correct. On an adult client, chest compressions should be done to a depth of at least 5 cm (2 inches.) to be effective. 6. The nurse is performing cardiopulmonary resuscitation (CPR) on a 10-month-old infant. The nurse times the rate of compressions to achieve a minimum of how many compressions per minute? Provide a numeric response. A. 50 B. 100 C. 150 D. 200 To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options B and D. If your answer is letter B, then you are correct. The rate of compressions for an infant during CPR is 100–120 compressions per minute, making the minimum rate of compressions 100 per minute. 7. A nurse witnesses an adult male collapse at the airport and an automated external defibrillator (AED) is brought to the scene. The nurse should perform which actions in using the device? A. Press the electrodes down firmly because the client has a hairy chest. B. Instruct another person at the scene to keep the airway open during delivery of the electric shock. C. Initiate CPR after 5 minutes if the AED has not restored a perfusing cardiac rhythm. D. Quickly wipe up the spilled coffee under the victim’s chest before using the AED. To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options B and D. If your answer is letter D, then you are correct. The client should not be lying in water or other liquid, which could lead to burns or to defibrillating another individual who comes in contact with the liquid during AED shock delivery. The electrodes should not be placed on hairy areas, or the site should be shaved. All people should stand clear of the individual during an AED shock to avoid being defibrillated themselves. CPR is initiated after 1 minute or whenever the series of shocks is terminated, as indicated by client condition. However, 5 minutes is excessive and could lead to permanent brain damage if the client survives. 8. A nurse is eating in a restaurant when a woman who is 8 months pregnant at the next table begins to choke. Which hand placement should the nurse use to perform the abdominal-thrust maneuver? A. Midsternum B. Lower sternum C. Midway between umbilicus and xiphoid process D. Midway between umbilicus and symphysis pubis To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options A and C. If your answer is letter A, then you are correct. In a pregnant client, the abdominal thrust maneuver is performed in a manner that avoids causing injury to the fetus. For this reason, the hand placement is at the midsternum. The lower sternum should be avoided to prevent accidental fracture of the xiphoid process, which could lead to internal injury. Midway between the umbilicus and the xiphoid process is the abdomen, which is contraindicated in the pregnant client. Midway between the umbilicus and the symphysis pubis is the lower abdomen, which is contraindicated in the pregnant client. 9. The long-term care nurse has been called to the aid of a resident who has become unconscious after choking in the dining room. After positioning the client on the back, which action should the nurse take next? A. Attempt to ventilate the client. B. Begin cardiopulmonary resuscitation, starting with chest compressions. C. Perform five abdominal thrusts. D. Perform five chest thrusts. To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options B and C. If your answer is letter B, then you are correct. After positioning the client on the back, the nurse would begin cardiopulmonary resuscitation, starting with chest compressions. The nurse would attempt to ventilate after inspecting the mouth. Abdominal thrusts are performed on responsive clients. Chest thrusts are performed in the adult only for pregnant or obese clients. 10. A nurse enters an adult client’s room and says, “Good morning!” while doing initial shift rounds after receiving report. The client does not respond. Put the nurse’s actions in order of priority. 1. Call for someone to announce a code blue. 2. Check for a carotid pulse. 3. Gently shake the client’s shoulder and ask, “Are you okay?” 4. Begin chest compressions. A. 3, 1, 2, 4 B. 1, 3, 2, 4 C. 3, 1, 4, 2 D. 1, 2, 3, 4 To make it easier for you to find the correct answer, let us remove the two incorrect options or distractors. So, we only have options A and D. If your answer is letter A, then you are correct. The first action of the nurse is to establish unresponsiveness. This can be done by shaking the shoulder and asking if the client is okay. The second action of the nurse would be to call for help. The third action of the nurse is to address circulation by checking the client’s pulse. If no pulse is present, the nurse should begin chest compressions. The 2015 CPR guidelines use the mnemonic CAB (chest compressions, airway, breathing).