Summary final exam from med surg book
3. This is the first intervention the nurse should implement after finding the client unresponsive on the floor.
The nurse finds the client unresponsive on the floor of the bathroom. Which action
should the nurse implement first?
1. Check the client for...
summary final exam from med surg book 3 this is the first intervention the nurse should implement after finding the client unresponsive on the floor the nurse finds the client unresponsive on the
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Summary final exam from med surg
book
3. This is the first intervention the nurse should implement after finding the client unresponsive on
the floor.
The nurse finds the client unresponsive on the floor of the bathroom. Which action
should the nurse implement first?
1. Check the client for breathing.
2. Assess the carotid artery for a pulse.
3. Shake the client and shout.
4. Notify the Rapid Response Team.
3. The sternum should be depressed one
and one-half (1.5) to two (2) inches
during compressions to ensure
adequate circulation of blood to the
body; therefore, the nurse needs to
correct the UAP.
The unlicensed assistive personnel (UAP) is performing cardiac compressions on an
adult client during a code. Which behavior warrants immediate intervention by the
nurse?
1. The UAP has hand placement on the lower half of the sternum.
2. The UAP performs cardiac compressions and allows for rescue breathing.
3. The UAP depresses the sternum 0.5 to one (1) inch during compressions.
4. The UAP asks to be relieved from performing compressions because of
exhaustion.
3. This is the most important intervention.
The nurse should always treat the
client based on the nurse's assessment
and data from the monitors; an intervention
should not be based on data
from the monitors without the nurse's
assessment.
Which intervention is most important for the nurse to implement when participating
in a code?
1. Elevate the arm after administering medication.
2. Maintain sterile technique throughout the code.
3. Treat the client's signs/symptoms; do not treat the monitor.
4. Provide accurate documentation of what happened during the code.
,1. This is the correct statement
explaining what an AED does when
used in a code.
The CPR instructor is discussing an automated external defibrillator (AED) during
class. Which statement best describes an AED?
1. It analyzes the rhythm and shocks the client in ventricular fibrillation.
2. The client will be able to have synchronized cardioversion with the AED.
3. It will keep the health-care provider informed of the client's oxygen level.
4. The AED will perform cardiac compressions on the client.
3. Ventricular fibrillation is the most
common dysrhythmia associated with
sudden cardiac death; ventricular fibrillation
is responsible for 65% to 85% of
sudden cardiac deaths
The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac
death?
1. The 84-year-old client exhibiting uncontrolled atrial fibrillation.
2. The 60-year-old client exhibiting asymptomatic sinus bradycardia.
3. The 53-year-old client exhibiting ventricular fibrillation.
4. The 65-year-old client exhibiting supraventricular tachycardia.
1. The chaplain should be called to help
address the client's family or significant
others. A small community hospital
does not have a 24-hour on-duty
pastoral service. A chaplain is part
of the code team in large medical
center hospitals.
Which health-care team member referral should be made by the nurse when a code
is being conducted on a client in a community hospital?
1. The hospital chaplain.
2. The social worker.
3. The respiratory therapist.
4. The director of nurses.
4. Nurses should protect themselves
against possible communicable disease,
such as HIV and hepatitis, and
should be protected if the client
vomits during CPR.
Which intervention is the most important for the nurse to implement when
performing mouth-to-mouth resuscitation on a client who has pulseless ventricular
,fibrillation?
1. Perform the jaw thrust maneuver to open the airway.
2. Use the mouth to cover the client's mouth and nose.
3. Insert an oral airway prior to performing mouth-to-mouth.
4. Use a pocket mouth shield to cover client's mouth.
3. Unexpected death occurring within
one (1) hour of the onset of cardiovascular
symptoms is the definition of
sudden cardiac death.
The nurse is teaching CPR to a class. Which statement best explains the definition of
sudden cardiac death?
1. Cardiac death occurs after being removed from a mechanical ventilator.
2. Cardiac death is the time the HCP officially declares the client dead.
3. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms.
4. The death is caused by myocardial ischemia resulting from coronary artery disease.
1. Gastric distention occurs from overventilating
clients. When compressions
are performed, the pressure will cause
vomiting which may cause aspiration
into the lungs.
Which statement explains the scientific rationale for having emergency suction
equipment available during resuscitation efforts?
1. Gastric distention can occur as a result of ventilation.
2. It is needed to assist when intubating the client.
3. This equipment will ensure a patent airway.
4. It keeps the vomitus away from the health-care provider
2. The crash cart is the mobile unit
with the defibrillator and all the
medications and supplies needed to
conduct a code.
Which equipment must be immediately brought to the client's bedside when a code
is called for a client who has experienced a cardiac arrest?
1. A ventilator.
2. A crash cart.
3. A gurney.
4. Portable oxygen.
4. The chart is a legal document, and the
code must be documented in the chart
and provide information needed in the
intensive care unit
, The nursing administrator responds to a code situation. When assessing the
situation, which role must the administrator ensure is performed for legal purposes
and continuity of care of the client?
1. A person is ventilating with an Ambu bag.
2. A person is performing chest compressions correctly.
3. A person is administering medications as ordered.
4. A person is keeping an accurate record of the code.
45mL/hr
The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine
drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of
lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?
2. Type 2 diabetes is a disorder usually
occurring around the age of 40, but it is
now being detected in children and
young adults as a result of obesity and
sedentary lifestyles. Nonhealing wounds
are a hallmark sign of type 2 diabetes.
This client weighs 248.6 pounds and
is short
An 18-year-old female client, 5′4′′ tall, weighing 113 kg, comes to the clinic for a
nonhealing wound on her lower leg, which she has had for two (2) weeks. Which
disease process should the nurse suspect the client has developed?
1. Type 1 diabetes.
2. Type 2 diabetes.
3. Gestational diabetes.
4. Acanthosis nigricans.
3. This result parallels a serum blood
glucose level of approximately 180 to
200 mg/dL. An A1c is a blood test reflecting
average blood glucose levels over a
period of three (3) months; clients with
elevated blood glucose levels are at risk
for developing long-term complications.
The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of
8.1%. Which interpretation should the nurse make based on this result?
1. This result is below normal levels.
2. This result is within acceptable levels.
3. This result is above recommended levels.
4. This result is dangerously high.
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