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Silvestri Chapter 16 Ed#54C

Silvestri Chapter 16 Ed#54C

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Published by Linda Kuglarz

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Published by: Linda Kuglarz on Oct 14, 2008
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Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 016 (edited file)—"Basic Life Support"10/14/08, Page 1 of 6, 5 FIG.ure(s), 0 Table(s), 3 Box(es)
16: Basic Life Support
PRACTICE QUESTIONS
1. A nurse on the day shift walks into a client's room and finds the client unresponsive. Theclient is not breathing and does not have a pulse, and the nurse immediately calls out for help.The next nursing action is which of the following?1. Ventilate with a mouth-to-mask device.2. Start chest compressions.3. Give the client oxygen.4. Open the airway.Answer: 4Rationale: The next nursing action would be to open the airway. Ventilation cannot be initiatedunless the airway is opened. Chest compressions are started after the airway is opened andventilation is initiated. Oxygen may be helpful at some point, but the airway is opened first.Test-Taking Strategy: Visualize the steps of basic life support to answer the question. Recallingthe ABCDs—airway, breathing, circulation, defibrillation or definitive treatment—will assist indirecting you to option 4. Review the steps of BLS if you had difficulty with this question.Level of Cognitive Ability:
 
ApplicationClient Needs:
 
Physiological IntegrityIntegrated Process:
 
 Nursing Process/ImplementationContent Area:
 
Adult Health/Cardiovascular Reference:
 
Christensen, B., & Kockrow, E. (2003).
 Foundations of nursing 
(4th ed.). St. Louis:Mosby, pp. 462, 616.2. A nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse understands that correct hand placement is locatedover the:1. Lower third of the sternum2. Upper half of the sternum3. Upper third of the sternum4. Lower half of the sternumAnswer: 4Rationale: Proper hand placement for chest compressions is determined by locating the notchwhere the rib margin meets the sternum, and placing the middle finger on this notch and theindex finger next to it. Then, the heel of the opposite hand is placed on the lower half of thesternum, close to the index finger. The first hand is removed and placed on top of the hand onthe sternum, and chest compressions are begun. This location is the lower half of the sternum.Test-Taking Strategy:
 
Use the process of elimination. Eliminate options 2 and 3 first becausethese locations would be ineffective. From the remaining options, visualizing the procedure andconsidering the anatomical location of the heart will direct you to option 4. If you had difficultywith this question, review the landmarks for chest compressions.Level of Cognitive Ability:
 
ApplicationClient Needs:
 
Physiological Integrity
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 016 (edited file)—"Basic Life Support"10/14/08, Page 2 of 6, 5 FIG.ure(s), 0 Table(s), 3 Box(es)
Integrated Process: Nursing Process/ImplementationContent Area: Adult Health/Cardiovascular Reference:
 
Christensen, B., & Kockrow, E. (2003).
 Foundations of nursing 
(4th ed.). St.Louis: Mosby, p. 616.3. A nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurserushes to the victim and determines the need to open the airway. The nurse opens the airway inthis victim by using which most appropriate method?1. Head tilt–chin lift2. Flexed position3. Modified head tilt–chin lift4. Jaw thrust maneuver Answer: 4Rationale: If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. Thehead tilt–chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.Test-Taking Strategy:
 
Use the process of elimination. Eliminate options 1 and 3 first becausethey are similar. Next, eliminate option 2, because this position would not open the airway. If you had difficulty with this question, review the appropriate methods to open an airway.Level of Cognitive Ability:
 
ApplicationClient Needs:
 
Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area:
 
Adult Health/NeurologicalReference:
 
Christensen, B., & Kockrow, E. (2003).
 Foundations of nursing 
(4th ed.). St. Louis:Mosby, pp. 614-615.4. A nurse is preparing to attempt to relieve an airway obstruction in a 3-year-old consciouschild. The nurse performs this maneuver by placing the hands between the:1. Umbilicus and the groin2. Groin and the abdomen3. Umbilicus and the xiphoid process4. Lower abdomen and the chestAnswer: 3Rationale:
 
To perform the Heimlich maneuver on a child, the rescuer stands behind the victimand places the arms directly under the victim's axillae and around the victim. The thumb side of one fist is placed against the victim's abdomen in the midline, slightly above the umbilicus andwell below the tip of the xiphoid process. The fist is grasped with the other hand, and up to fivethrusts are delivered. Care must be taken not to touch the xiphoid process or the lower marginsof the rib cage, because force applied to these structures may damage internal organs.Test-Taking Strategy: Use the process of elimination, noting the age of the child. Eliminateoptions 1 and 2 first because they are similar. From the remaining options, considering theanatomical location and the effect of the maneuver in dislodging an obstruction will direct you tooption 3. If you had difficulty with this question, review the correct hand placement for theHeimlich maneuver.Level of Cognitive Ability:
 
Application
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 016 (edited file)—"Basic Life Support"10/14/08, Page 3 of 6, 5 FIG.ure(s), 0 Table(s), 3 Box(es)
Client Needs:
 
Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Child HealthReference:
 
Linton, A., & Maebius, N. (2003)
 Introduction to medical-surgical nursing 
(3rd ed.).Philadelphia: W.B. Saunders, p. 192.5. A nurse is performing basic life support (BLS) on a 7-year-old child. The nurse delivers howmany breaths per minute to the child?1. 122. 163. 184. 20Answer: 4Rationale: In a child between the ages of 1 and 8 years, 20 breaths per minute are delivered.Options 1, 2, and 3 are incorrect.Test-Taking Strategy:
 
Use the process of elimination and note the age of the child. Recalling thenormal respiratory rate in a child of this age will assist in directing you to option 4. If you haddifficulty with this question, review BLS for a child.Level of Cognitive Ability:
 
ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Child HealthReference: Christensen, B., & Kockrow, E. (2003).
 Foundations of nursing 
(4th ed.). St. Louis:Mosby, p. 615.6. A nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performingchest compressions, the nurse understands that the compression rate is at least:1. 60 times per minute2. 80 times per minute3. 100 times per minute4. 160 times per minuteAnswer: 3Rationale:
 
In an infant, the rate of chest compressions is at least 100 times per minute. Options1 and 2 identify rates that are too low, and option 4 identifies a rate that is too high.Test-Taking Strategy:
 
Use the process of elimination, considering the normal heart rate of aninfant. Eliminate options 1 and 2 because of the low rates identified in the options. Eliminateoption 4 because this rate would be much too rapid for an infant. If you had difficulty with thisquestion, review CPR for an infant.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process:
 
 Nursing Process/ImplementationContent Area:
 
Child HealthReference: Christensen, B., & Kockrow, E. (2003).
 Foundations of nursing 
(4th ed.). St.Louis: Mosby, p. 618.

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