Nokea
CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR?
- A. Assessing an EKG pattern with each compression
- B. Assessing a palpable carotid pulse during each compression
- C. Assuring a compression depth of to 2 in
- D. Observing pupils that change from pinpoint to dilated
Correct Answer: B
Rationale: During effective CPR, a carotid pulse is palpable during each compression.
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The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54 P 102 RR 22. What does the nurse recognize that these symptoms indicate?
- A. Inadequate perfusion
- B. Circulatory shock
- C. Massive vasodilation
- D. Heart failure
Correct Answer: B
Rationale: Shock results from failure of the circulatory system to provide sufficient blood circulation.
A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take?
- A. Remove it with sterile tweezers.
- B. Soak the area with a cold compress.
- C. Scrape the stinger with the side of a knife.
- D. Squeeze the surrounding tissue to expel the stinger.
Correct Answer: C
Rationale: The stinger should be removed with the side of a knife by scraping to avoid forcing more venom into the skin.
If a spinal injury is suspected before the rescuer starts CPR the trachea should be opened with a __ maneuver.
Correct Answer: thrust
Rationale: The jaw-thrust maneuver does not hyperextend the neck.
The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?
- A. Slow labored breathing
- B. Hot flushed skin
- C. Edematous extremities
- D. Weak thready pulse
Correct Answer: D
Rationale: The pulse becomes weak and thready with hypovolemic shock.
A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?
- A. Place several layers of gauze dressing over the wound.
- B. Place the patient in a supine position.
- C. Cover the wound with an airtight dressing taped on three sides.
- D. Turn the patient to the left side.
Correct Answer: C
Rationale: Sucking chest wounds should be dressed with a flutter dressing so that air can escape the pleural space, but no more air can be sucked in.