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Performance
Exit
N566: EAQ NCLEX CC - Quiz #2
Due Sep 21, 2022 by 9:00 am
Final Score
90%
27 out of 30 questions answered correctly
Completed on Sep 15, 2022 8:42 pm
Incorrect (3)
In which order would the nurse perform interventions for the jaw-thrust
maneuver on an unconscious client admitted in the emergency unit
with traumatic injuries and a suspected a spinal injury?
1.
Lay the client in the supine position.
2.
Stand or kneel at the top of the client’s head.
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3.
Grasp the client’s lower jaw and lift forward with both hands without tilting the head.
4.
Place one hand on each side of the client’s head.
5.
Rest elbows on the surface.
Rationale
Jaw-thrust maneuver is performed to open the airway of an unconscious client with
possible spinal or neck injury. The client should be laid in supine position and the
nurse would kneel at the top of the client’s head to initiate the procedure. This position
allows access to the peritoneal, thoracic, and pericardial regions. This should be
followed by resting the elbows on the surface and placing one hand on each side of the
client’s head. Grasping the client’s lower jaw and lifting forward with both hands
without tilting the head helps lift of the epiglottis and enlarge the laryngeal inlet and
the pharynx, thereby resulting in improved ventilation.
Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the
options presented. For example, you might be asked the steps of performing an action
or skill such as those involved in medication administration.
Which condition of a client with hemorrhagic stroke resulting from a
motor bike accident requires immediate attention?
Glasgow Coma score of 10
Body temperature of 81.2°F
Oxygen (O 2) saturation of 90%
Presence of carotid pulse with blood pressure (BP) of 80 mm Hg
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Rationale
Severe hypothermia such as body temperature of 81.2°F must be immediately
corrected by infusing warm fluids and blood. This helps prevent hypothermia-related
complications. A Glasgow Coma score of 10 needs medium priority because it does
indicate immediate danger to the client. O 2 saturation of 90% indicates a manageable
status. Presence of carotid pulse with BP of 80 mm Hg is acceptable.
Test-Taking Tip: Apply your critical thinking and identify the value of each observation
to select the correct answer.
Which are the priority emergency assessments the nurse will perform
for a client with bomb blast injuries? Select all that apply. One, some,
or all responses may be correct.
Some correct answers were not selected
Airway
Breathing
Circulation
Giving comfort measures
Facilitating family presence
Exposure or environmental control
Rationale
The primary survey focuses on airway-breathing-circulation (ABC) and environmental
control. These are surveyed during emergency assessments in a primary survey to
identify life-threatening conditions and to analyze the appropriate interventions.
Giving comfort measures and facilitating family presence are performed in a secondary
survey of emergency assessment followed by a primary survey.
Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early,
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or best are important. Similarly, words such as only, always, never, and all in the
alternatives are frequently evidence of a wrong response. No real absolutes exist in life;
however, every rule has its exceptions, so answer with care.
Correct (27)
A client is diagnosed with a pituitary tumor. Before surgery for tumor
removal, the probability of an aneurysm must be determined. The nurse
anticipates that which diagnostic test will be prescribed?
Skull x-ray
Angiogram
Computed tomography
Magnetic resonance imaging
Rationale
A localized swelling or inflammation in an arterial wall is called an aneurysm. An
angiogram is a diagnostic procedure used to visualize blood flow in arteries. Therefore,
an angiogram should be prescribed to rule out the probability of an aneurysm before
pituitary tumor removal surgery. A skull x-ray will reveal tumor-induced changes in the
bony sella turcica, which houses the pituitary gland. Computed tomography and
magnetic resonance imaging are useful to obtain distinct images of bony and softtissue lesions.
When the emergency department nurse is caring for a client with acute
coronary syndrome who reports severe crushing chest pressure, which
prescribed medication is best for the nurse to administer?
Ibuprofen 650 mg orally
Acetaminophen 650 mg orally
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Nitroglycerin 0.4 mg sublingually
Morphine sulfate 4 mg intravenously
Rationale
Morphine will relieve pain and decrease sympathetic nervous system stimulation
associated with pain. Ibuprofen will not work quickly to reduce pain. Acetaminophen
also will not be rapidly effective. Nitroglycerin is ineffective in relieving ischemic pain
with myocardial infarction.
A client is admitted to the hospital with partial- and full-thickness burns
of the chest and face sustained while trying to extinguish a brush fire.
Which concern is the nurse’s priority?
Loss of skin integrity caused by the burns
Potential infection as a result of the burn injury
Inadequate gas exchange caused by smoke inhalation
Decreased fluid volume because of the depth of the burns
Rationale
Maintaining a patent airway is the priority; because of the proximity of the chest and
face to the nose and mouth, inhalation burns also may have occurred. Although loss of
skin integrity caused by the burns is important, it is not the priority at this time.
Although potential for infection as a result of the burn injury is important, it is not the
priority. Although fluid needs are important, the gas exchange is priority.
When the nurse is caring for a client who has cardiogenic shock, which
clinical manifestations will be expected? Select all that apply. One,
some, or all responses may be correct.
Rapid pulse
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Deep respirations
Warm, flushed skin
Increased blood pressure
Decreased urinary output
Rationale
The heart rate increases (tachycardia) to meet the body’s oxygen demands and circulate
blood to vital organs; the pulse is weak and thready because of peripheral
vasoconstriction. The urinary output decreases because increased catecholamines and
activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in
the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and
clammy because of vasoconstriction caused by the shunting of blood to vital organs.
The blood pressure is decreased, not increased, because of continued hypoperfusion
and multiorgan failure.
Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing
exams have specified time limits, you should pace yourself during the practice testing
period accordingly. It is helpful to estimate the time that can be spent on each item
and still complete the examination in the allotted time. You can obtain this figure by
dividing the testing time by the number of items on the test. For example, a 1-hour
(60-minute) testing period with 50 items averages 1.2 minutes per question. The
NCLEX exam is not a timed test. Both the number of questions and the time to
complete the test varies according to each candidate's performance. However, if the
test taker uses the maximum of 5 hours to answer the maximum of 265 questions,
each question equals 1.3 minutes.
The nurse is caring for a client whose mechanical ventilator settings
include the use of positive end-expiratory pressure (PEEP). This
treatment improves oxygenation primarily through which mechanism of
action?
Providing more oxygen to lung tissue
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Forcing pressure into lung tissue, which improves gas exchange
Opening collapsed alveoli and keeping them open
Opening collapsed bronchioles, which allows more oxygen to reach lung
tissue
Rationale
The primary mechanism of PEEP is to deliver positive pressure to the lung at the end
of expiration. This helps open collapsed alveoli and keeps them open. With the primary
mechanism of PEEP to open the alveoli and maintain them open, exchange of carbon
dioxide and oxygen can take place more efficiently, thus improving oxygenation by
providing more oxygen to the lung tissue and improving gas exchange. PEEP does not
force pressure into lung tissue. PEEP may have an indirect effect on opening
bronchioles.
STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes
you laugh, reading something funny, or sharing humor with friends helps decrease
stress.
Which is the priority focus of nursing care for a client with a spinal cord
injury during the immediate postinjury period?
Inhibiting urinary tract infections
Preventing contractures and atrophy
Avoiding flexion or hyperextension of the spine
Preparing the client for vocational rehabilitation
Rationale
The priority of care at this time is to protect the spine from additional damage to the
traumatized area while it heals. Infection can result from prolonged immobility;
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although important, it is not the immediate priority. Although important, preventing
contractures and atrophy is not the priority in the immediate postinjury period.
Vocational rehabilitation will assume greater importance after the client’s condition
stabilizes.
After an anterior fossa craniotomy, a client is placed on controlled
mechanical ventilation. Which action would the nurse take to promote
adequate cerebral blood flow?
Clear the ear of draining fluid.
Discontinue anticonvulsant therapy.
Position the client’s head turned to the left.
Monitor serum carbon dioxide levels.
Rationale
Carbon dioxide levels must be maintained because carbon dioxide can cause
vasodilation, increasing intracranial pressure and decreasing blood flow. The fluid may
be cerebrospinal fluid; clearing the ear may cause further damage. Because of
manipulation during a craniotomy, anticonvulsants are given prophylactically to
prevent seizures. Turning the neck impairs venous drainage from the head and may
increase intracranial pressure, thus decreasing cerebral blood flow.
Which intervention would the nurse implement for a 5-year-old child
admitted to the burn unit with severe burns?
Giving ice chips as desired
Permitting milk if it has been iced
Maintaining nothing-by-mouth (NPO) status for 24 to 48 hours
Limiting oral fluid to 15 mL every 4 hours
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Rationale
NPO status is maintained during the early emergency/resuscitative phase because of
the probability of paralytic ileus. It is unsafe to offer ice chips because the fluid that is
ingested interferes with monitoring and control of the child’s fluid and electrolyte
status. It is unsafe to offer oral fluids, not only because of the danger of paralytic ileus,
but also because they interfere with monitoring and control of the child’s fluid and
electrolyte status.
Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing
exams have specified time limits, you should pace yourself during the practice testing
period accordingly. It is helpful to estimate the time that can be spent on each item
and still complete the examination in the allotted time. You can obtain this figure by
dividing the testing time by the number of items on the test. For example, a 1-hour
(60-minute) testing period with 50 items averages 1.2 minutes per question. The
NCLEX exam is not a timed test. Both the number of questions and the time to
complete the test vary according to each candidate’s performance. However, if the test
taker uses the maximum of 5 hours to answer the maximum of 265 questions, each
question equals 1.3 minutes.
Which emergency staff member would monitor vital signs, perform
basic wound care, and ensure spinal immobilization for a client
admitted to the emergency department after a train derailment?
Paramedics
Prehospital care providers
Emergency medicine physician
Emergency medical technicians
Rationale
Emergency medical technicians are the appropriate emergency staff members who
would monitor vital signs, perform basic wound care, and ensure spinal
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immobilization, because these are basic life support (BLS) interventions. Paramedics
are qualified to perform advanced life support (ALS) measures. Prehospital care
providers are the first caregivers who help in transportation to the emergency
department. Emergency medicine physicians receive specialized education and
training in emergency client management.
Which nursing intervention is the priority when the nurse notices that
the client receiving a blood transfusion is having an acute hemolytic
reaction?
Stop the blood transfusion immediately.
Report to the primary health care provider.
Recheck identifying tags and numbers on the client.
Maintain a patent intravenous (IV) line with saline solution.
Rationale
An incompatible blood transfusion can result in an acute hemolytic reaction in the
client. During acute hemolytic reactions, the nurse would stop a blood transfusion as a
priority nursing intervention. After stopping the blood transfusion, the nurse would
report it to the primary health care provider. The nurse can then recheck the client’s
identifying tags and numbers and maintain a patent IV line with saline solution.
The nurse is caring for a client with a body surface burn injury of 55%.
Which information will the nurse consider when planning care for this
client?
Is prone to poor healing because of a hypermetabolic state
Has a decreased risk of infection when in a hypermetabolic state
Needs a cool environment to decrease caloric need
Will need 20 calories/kg during the healing process
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Rationale
Burn injuries cause a hypermetabolic state. This results in lipid and protein catabolism,
which in turn can inhibit wound healing. A hypermetabolic state increases the risk for
slowed wound healing, increasing the chance for infection. Cooling the environment
would cause an increase in caloric need as the body tries to warm to core temperature.
Clients with burn injuries require increased calories and protein to promote wound
healing. For an adult client, 20 calories/kg does not provide an adequate increase of
calories or protein for the hypermetabolic state associated with burns.
Which would be included in the plan of care for a preterm newborn who
is given oxygen by way of a hood?
Ensuring that the oxygen is continuously warmed and humidified
Monitoring to see that the infant’s skin and mucous membranes are
remaining bright pink
Informing the parents that oxygen will be given at 4 L/min and that blindness
is not a risk
Checking the oxygen level in the hood every 4 hours and monitoring oxygen
saturation continuously
Rationale
The oxygen must be warmed and humidified to help prevent hypothermia and drying
of the mucous membranes. Bright-pink skin and mucous membranes may indicate an
excessively high arterial oxygen level, which predisposes the infant to retinopathy of
prematurity. Blindness develops with an excessive arterial oxygen level, which may
occur with any percentage of oxygen. The oxygen level is checked every 1 to 2 hours
and adjusted in response to the infant’s condition.
Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of
an examination. Relaxation techniques such as deep breathing, imagery, head rolling,
shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with
feet flat on the floor can effectively reduce tension while causing little or no distraction
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to those around you. It is recommended that you practice one or two of these
techniques intermittently to avoid becoming tense. The more anxious and tense you
become, the longer it will take you to relax.
Which is the focus of nursing care for a newborn with respiratory
distress syndrome?
Tapping the toes to stimulate respirations
Turning the infant frequently to prevent apnea
Maintaining oxygen concentration at 40% to support respiration
Keeping the infant warm to maintain body temperature at 98°F (37°C)
Rationale
A warm environment is most important, because if the neonate has to maintain body
temperature it will further compromise physical status by increasing metabolic activity
and oxygen demand. Frequent turning and stimulation such as tapping the toes are
both contraindicated, because increased activity increases oxygen demands. The
oxygen percentage will vary with the neonate’s Po 2 values; the concentration of oxygen
should never be set at a fixed amount.
Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing
exams have specified time limits, you should pace yourself during the practice testing
period accordingly. It is helpful to estimate the time that can be spent on each item
and still complete the examination in the allotted time. You can obtain this figure by
dividing the testing time by the number of items on the test. For example, a 1-hour
(60-minute) testing period with 50 items averages 1.2 minutes per question. The
NCLEX exam is not a timed test. Both the number of questions and the time to
complete the test varies according to each candidate’s performance. However, if the
test taker uses the maximum of 5 hours to answer the maximum of 265 questions,
each question equals 1.3 minutes.
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Which action would the nurse anticipate taking when a client develops
third degree atrioventricular block with a heart rate of 30 beats/minute?
Assist with rapid defibrillation.
Prepare for synchronized cardioversion.
Obtain the transcutaneous pacemaker.
Initiate cardiopulmonary resuscitation.
Rationale
Transcutaneous pacing is used for emergency treatment of bradycardia, because it is
noninvasive and can be rapidly initiated. Defibrillation would be used for ventricular
fibrillation. Synchronized cardioversion would be used as the treatment for rapid atrial
or ventricular rhythms such as atrial fibrillation, atrial flutter, and ventricular
tachycardia. Cardiopulmonary resuscitation is used when the client has cardiac or
respiratory arrest.
A client who had extensive pelvic surgery 24 hours ago becomes
cyanotic, is gasping for breath, and reports right-sided chest pain.
Which action would the nurse take first?
Obtain vital signs.
Initiate a cardiac arrest code.
Administer oxygen using a facemask.
Encourage the use of an incentive spirometer.
Rationale
The client is exhibiting the classic signs and symptoms associated with the
postoperative complication of pulmonary embolus. Initially oxygen should be
administered to increase the amount of oxygen being delivered to the pulmonary
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capillary bed. Obtaining the vital signs should be done after oxygen therapy is
instituted. The client is not yet experiencing a cardiac arrest, and a code should not be
initiated. Although deep breathing (such as that used with an incentive spirometer)
and coughing are important after surgery, they will not be effective in resolving
hypoxemia caused by a pulmonary embolus.
When a norepinephrine intravenous infusion is prescribed for a client in
septic shock, which intravenous line would the nurse choose for the
infusion?
Implanted port
Midline catheter
18-gauge peripheral venous catheter
Peripherally inserted central catheter (PICC) line
Rationale
Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the
intradermal or subcutaneous tissues. It is best infused through a central line, such as a
PICC line. Implanted ports are also central lines, used mainly for chemotherapy, but
require specialized needles and staff who are trained in accessing the port. Midline
catheters are peripherally inserted in the antecubital area or upper arm and are not
recommended for infusion of vesicants because large amounts of fluid may escape
into the subcutaneous tissues before the infiltration is noted. Infiltration of fluids
occurs more frequently when fluids are infused through the smaller and more fragile
peripheral veins.
Test-Taking Tip: Do not select answers that contain exceptions to the general rule,
controversial material, or responses that appear to be degrading.
Which diagnostic test result will the nurse review after noticing large U
waves on the electrocardiogram (ECG) for a client who was just admitted
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to the cardiac unit?
Troponin T
Serum potassium
Oxygen saturation
C-reactive protein
Rationale
Large U waves suggest possible hypokalemia, which should be corrected to decrease
dysrhythmia risk. The nurse may also review the other values, but these are unrelated
to the presence of U waves. Troponin T levels increase with myocardial infarction.
Oxygen saturation changes do not cause U waves. C-reactive protein elevations
indicate inflammation but will not cause changes in the ECG.
STUDY TIP: Rest is essential to the body and brain for good performance; think of it as
recharging the battery. A run-down battery provides only substandard performance.
For most students, it is better to spend 7 hours sleeping and 3 hours studying than to
cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's
efficiency will balance out the difference in the time spent studying. Knowing your
natural body rhythms is necessary when it comes to determining the amount of sleep
needed for personal learning efficiency.
When the chest x-ray for a client who has arrived at the emergency
department with chest trauma shows multiple fractured ribs, which
action will the nurse take next?
Administer the prescribed morphine sulfate.
Assist the client to take deep breaths and cough.
Check for paradoxical movement of the chest wall.
Teach the client about ways to manage rib pain.
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Rationale
Flail chest can occur when multiple ribs are fractured and can compromise breathing
efforts because of paradoxical movement during inspiration and expiration. Flail chest
may require intubation and mechanical ventilation. Analgesic medication
administration will be needed, because rib fractures make breathing painful, but
further assessment of the client’s ventilatory effort is needed prior to giving narcotic
pain medications. The client with fractured ribs will need to deep breathe and cough to
prevent atelectasis and pneumonia, but assessing for possible flail chest would be done
first. Education about management of pain is needed, but this would be done after
assessing for possible respiratory distress caused by flail chest.
STUDY TIP: Answer every question. A question without an answer is the same as a
wrong answer. Go ahead and guess. You have studied for the test and you know the
material well. You are not making a random guess based on no information. You are
guessing based on what you have learned and your best assessment of the question.
A client who had an infratentorial craniotomy is admitted to the
intensive care unit after discharge from the postanesthesia care unit.
Frequent assessments reveal that the client's intracranial pressure is
increasing. Which action would the nurse take?
Notify the health care provider.
Elevate the head of the bed.
Reduce the prescribed flow rate of intravenous (IV) fluid.
Administer the next scheduled dose of osmotic diuretic early.
Rationale
Immediate corrective therapy based on current assessments must be implemented.
After an infratentorial craniotomy the client is positioned flat on one side with the head
on a small, firm pillow unless otherwise instructed by the health care provider.
Administering medication or adjusting an IV rate is a dependent function of the nurse,
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and the prescription must be followed exactly. Changes to prescriptions may be
received when the health care provider is notified.
STUDY TIP: Remember that intelligence plays a vital role in your ability to learn.
However, being smart involves more than just intelligence. Being practical and
applying common sense are also part of the learning experience.
A preschool-age child is about to be admitted to the pediatric intensive
care unit after surgery for the removal of a brain tumor. Which nursing
action would prompt the nurse manager to immediately intervene?
Places a hypothermia blanket at the bedside
Adjusts the bed to the Trendelenburg position
Obtains electronic equipment for monitoring of vital signs
Secures a pump to administer the prescribed intravenous fluids
Rationale
Raising the foot of the bed increases blood flow to the brain, thereby increasing
intracranial pressure. An increase in temperature may occur after a craniotomy as a
result of stimulation of the hypothalamus. A hypothermic blanket should be ready if
the temperature climbs precipitously. Monitoring of vital signs is a critical component
of postoperative care. Intravenous infusions must be regulated precisely to minimize
the possibility of cerebral edema.
Test-Taking Tip: If the question asks for an immediate action or response, all of the
answers may be correct, so base your selection on identified priorities for action.
Which physiologic responses to bronchiolitis would the nurse expect to
observe in the pediatric intensive care unit? Select all that apply. One,
some, or all responses may be correct.
Wheezing
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Bradycardia
Sternal retractions
Nasal flaring
Prolonged expiratory phase
Rationale
Bronchiolitis in most infants is caused by respiratory syncytial virus. Wheezing occurs
as the air passages narrow, resulting in the typical whistling sound. As breathing
becomes more difficult, the infant must expend more energy and use accessory
muscles of respiration to breathe. Nasal flaring is a predominant characteristic of
bronchiolitis. The infectious and inflammatory changes narrow the bronchial passage,
making it difficult for air to leave the lungs. As a result of increased respiratory effort
and decreased oxygen exchange, tachycardia, not bradycardia, develops. Breath sounds
are diminished because of edema of the bronchiolar mucosa and filling of the lumina
with mucus and exudate.
Which action would the nurse anticipate implementing when caring for
a client with acute respiratory distress syndrome who is intubated and
on mechanical ventilation?
Deflate the endotracheal tube cuff hourly.
Schedule a change in ventilator tubing every 24 hours.
Determine need for suctioning based on client assessments.
Leave fraction of inspired oxygen (FiO 2) at the highest setting as the client
oxygenation improves.
Rationale
Suction is likely to be needed and will be done based on assessment data such as client
oxygen saturation, breath sounds, and activation of the high pressure alarm signifying
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endotracheal tube obstruction. The endotracheal tube cuff is kept inflated to protect
the lower airways and improve delivery of breaths to the lungs. Research indicates that
daily changes in ventilator tubing increase the risk for ventilator-associated
pneumonia; the ventilator tubing should be changed only when soiled. Because high
FiO 2 levels can cause damage to the lungs, the FiO 2 is reduced as the client’s
oxygenation improves.
Test-Taking Tip: Pace yourself while taking a quiz or exam. Read the entire question
and all answer choices before answering the question. Do not assume that you know
what the question is asking without reading it entirely.
Which core temperature is the lowest temperature at which the nurse
performing a rewarming procedure on a client with severe hypothermia
by administering warmed intravenous fluids will stop the rewarming?
86°F (30°C)
91.4°F (33°C)
96.8°F (36°C)
100.4°F (38°C)
Rationale
A rewarming procedure should be performed carefully, because it places the client at
risk for 'after drop,' a further drop in core temperature. This can lead to hypotension
and dysrhythmias. So, active rewarming should be discontinued once the core
temperature reaches 89.6°F to 93.2°F (32°C–34°C). Administering warmed intravenous
fluids is a type of active rewarming. The nurse will stop this procedure when client’s
core temperature reaches 92.4°F (33°C). A core temperature of 86°F (30°C) indicates
that moderate to severe hypothermia is present. The nurse would continue the
rewarming procedure at this temperature. A core temperature of 96.8°F (36°C) is
outside the recommended range in which active rewarming should be performed. At
this temperature, the client is mildly hypothermic, and an active rewarming procedure
is not required. However, this is not the lowest temperature at which the nurse would
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the active rewarming procedure. A core temperature of 100.4°F (38°C) is in the normal
range; the nurse would have stopped the active rewarming procedure long before this
temperature is reached.
Which client condition would the nurse keep in mind while performing
a rewarming procedure in a client with severe hypothermia?
The client is at risk for hypertension from rewarming shock.
The client should be monitored for after drop during rewarming.
The cold myocardium should be stimulated in a hypothermic client.
The core of the client with severe hypothermia should be warmed after the
extremities.
Rationale
Rewarming places the client at risk for after drop, a further drop in core temperature.
This occurs when cold peripheral blood returns to the central circulation. So, the core
temperature of the client should be monitored carefully during rewarming. Rewarming
shock can produce hypotension, not hypertension. The cold myocardium is extremely
irritable, making it vulnerable to dysrhythmias. Gentle handling is essential to prevent
the myocardium from being stimulated. Clients with moderate to severe hypothermia
should have the core warmed before the extremities to prevent rewarming shock.
When the nurse initiates continuous cardiac monitoring and maintains
oxygen saturation and end-tidal carbon dioxide on a client who survived
a fire, which type of emergency assessment is being performed?
Focused adjuncts
Full set of vital signs
Comfort measures
Family presence
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Rationale
Emergency assessment of focused adjuncts is used to determine the need for
additional procedures in a secondary survey. Initiating a continuous electrocardiogram,
maintaining oxygen saturation and end-tidal carbon dioxide, inserting a gastric tube,
and obtaining blood for laboratory studies are some of the interventions performed
during emergency assessment of focused adjuncts. Emergency assessment of the full
set of vital signs is performed to obtain temperature, heart rate, and blood pressure.
The nurse gives comfort measures to assess, treat, and reassess for pain and anxiety.
Facilitating family presence involves determining the caregiver’s desire to be present
during invasive procedures and/or cardiopulmonary resuscitation.
Test-Taking Tip: Identify option components as correct or incorrect. This may help you
identify a wrong answer. Example: If you are being asked to identify a diet that is specific to
a certain condition, your knowledge about that condition would help you choose the correct
response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).
Which nursing intervention would be of most benefit to the client with
a compromised airway the nurse noticed while performing resuscitation
during the primary survey?
Preparing for chest decompression if needed
Monitoring vital signs, especially blood pressure and pulse
Preventing hypothermia using blankets and heating devices
Preparing for endotracheal intubation and mechanical ventilation
Rationale
Preparing for endotracheal intubation and mechanical ventilation ensures airway
patency during the primary survey to reduce the severity of airway compromise.
Preparing for chest decompression is done during the primary survey when there are
no breath sounds. Monitoring vital signs, especially blood pressure and pulse, is
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performed to assess circulatory disorders. Preventing hypothermia using blankets and
heating devices is done during the exposure assessment.
Which type of support provides immediate relief to the client with
tongue occlusion, loss of gag reflex, alterations in level of
consciousness, oxygen (O 2) saturation of 40 mm Hg, and carbon
dioxide (CO 2) saturation of 75 mm Hg?
Tracheotomy
Laryngeal repair
Abdominal thrust maneuver
Autotitrating positive airway pressure
Rationale
Upper airway obstruction may occur with tongue occlusion, which is associated with
loss of gag reflex and alterations in the level of consciousness. The client suffering
from severe hypoxia (O 2 saturation of 40 mm Hg) and who is hypercapnic (CO 2
saturation of 75 mm Hg) requires an emergency tracheotomy for relief within 2
minutes. Laryngeal repair is performed to prevent laryngeal stenosis and cover
exposed cartilage. The abdominal thrust maneuver clears upper airway obstruction
caused by a foreign body. Autotitrating positive airway pressure resets the pressure
throughout the breathing cycle in a client with severe sleep apnea.
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