Introduction Critical Care Nursing 7th Edition by Sole Klein-Test Bank

Introduction Critical Care Nursing 7th Edition by Sole Klein-Test Bank

Chapter 10: Rapid Response Teams and Code Management
Sole: Introduction to Critical Care Nursing, 7th Edition

MULTIPLE CHOICE

1. The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest?
a. Bag-valve-mask at FiO2 of 100%
b. Bag-valve-mask at FiO2 of 50%
c. Mouth-to-mask ventilation with supplemental oxygen
d. Non-rebreather mask at FiO2 of 100%

ANS: A
Oxygen can be delivered via mouth to mask or with a bag-valve device connected to a mask or endotracheal tube. During resuscitation efforts, 100% oxygen is administered.

DIF: Cognitive Level: Apply/Application REF: p. 212 | Table 10-3
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity

2. Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting?
a. Automatic external defibrillator
b. Carbon dioxide detector
c. Pocket mask
d. Transcutaneous pacemaker

ANS: A
Because of the ease of use and efficacy in treating lethal ventricular dysrhythmias, automatic external defibrillators are recommended to be placed in a variety of public settings where they may be used by laypersons.

DIF: Cognitive Level: Understand/Comprehension REF: p. 218
OBJ: Identify equipment used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity

3. When doing manual ventilations during a code, the nurse would administer ventilations following which guideline?
a. Approximately 8 to 10 breaths per minute
b. During the fifth chest compression
c. Every 3 seconds or 20 times per minute
d. While compressions are stopped

ANS: A
Manual ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.

DIF: Cognitive Level: Apply/Application REF: p. 212 | Table 10-3
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity

4. The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction. Suddenly the monitor alarms and the screen shows a flat line. What action should the nurse take first?
a. Administer epinephrine by intravenous push.
b. Begin chest compressions.
c. Check patient for unresponsiveness.
d. Defibrillate at 360 J.

ANS: C
The first intervention is to assess unresponsiveness.

DIF: Cognitive Level: Apply/Application REF: p. 214
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity

5. During a code, the nurse would place paddles for anterior defibrillation in what locations?
a. Second intercostal space, left sternal border and fourth intercostal space, left midclavicular line
b. Second intercostal space, right sternal border and fourth intercostal space, left midaxillary line
c. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line
d. Fourth intercostal space, right sternal border and fifth intercostal space, left midclavicular line

ANS: C
Anterior paddle placement is used most often for defibrillation. In the anterior method, one paddle or adhesive electrode pad is placed at the second intercostal space to the right of the sternum, and the other paddle or adhesive electrode pad is placed at the fifth intercostal space, midaxillary line, to the left of the sternum.

DIF: Cognitive Level: Apply/Application REF: p. 216 | Figure 10-8
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity

6. During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex?
a. P
b. R
c. S
d. T

ANS: B
During cardioversion, the electrical shock is synchronized to deliver shock on the R wave. This is to prevent the shock from being delivered during repolarization (T wave). Ventricular fibrillation may occur if the shock is delivered on the T wave.

DIF: Cognitive Level: Understand/Comprehension REF: p. 218
OBJ: Identify equipment used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity