Nokea
The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching? Select all that apply.
- A. A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator
- B. Depth of chest compressions for infants should be half the depth of the anterior-posterior chest diameter
- C. Rescuers should place the heel of one hand on the lower sternum when delivering chest compressions to infants
- D. The ratio of chest compressions to breaths during CPR by a single rescuer is 15:2 for infants
- E. You should assess the infant’s brachial pulse for no longer than 10 seconds
Correct Answer: A,E
Rationale: Two minutes of CPR before defibrillator retrieval and assessing the brachial pulse for ≤10 seconds align with infant CPR guidelines. Compression depth is about one-third the chest, two fingers are used, and the ratio is 30:2 for a single rescuer.
You may also like to solve these questions
A client is brought to the emergency room with injuries sustained in an auto accident. While performing his assessment, the nurse notes the presence of Cullen's sign. Cullen's sign is suggestive of:
- A. A neurological injury
- B. A ruptured spleen
- C. A bowel perforation
- D. Retroperitoneal bleeding
Correct Answer: D
Rationale: Cullen's sign, a bluish discoloration around the umbilicus, indicates retroperitoneal or intra-abdominal bleeding, often due to trauma or conditions like pancreatitis. It is not specific to neurological injury, spleen rupture, or bowel perforation.
The health care provider prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?
- A. I can stop taking the medication once my symptoms improve
- B. I must eat a healthy diet and exercise regularly to reduce weight gain
- C. I should feel better within 1 week after starting this medication
- D. I will experience improved sexual performance with this medication
Correct Answer: B
Rationale: Paroxetine may cause weight gain, so a healthy diet and exercise are appropriate. Stopping abruptly risks withdrawal, full effects take weeks, and sexual dysfunction is a common side effect.
An adult is admitted for surgery today. Immediately after administering the preoperative medications of meperidine and atropine, the nurse notes that the operative permit has not been signed. Which action should the nurse take?
- A. Have the client sign the operative permit immediately before the medications take effect
- B. Have the client's next of kin sign the permission form
- C. Ask the client if he/she is willing to undergo surgery, sign the form for the client, and indicate the nurse's name as witness to the client's verbal consent
- D. Report it to the physician so the surgery can be delayed until the client can legally sign a consent form
Correct Answer: D
Rationale: Preoperative medications like meperidine impair judgment, making consent invalid post-administration. Reporting to the physician to delay surgery ensures legal and ethical consent.
Which tasks can the licensed practical nurse appropriately delegate to unlicensed assistive personnel? Select all that apply.
- A. Assist the nurse in ambulating a client 1 day post abdominal surgery
- B. Measure and empty drainage output into a bulb drain
- C. Monitor for redness and swelling at a client’s IV insertion site
- D. Provide extra blankets at the client’s request
- E. Take family members to the waiting room after a client goes into surgery
Correct Answer: A,B,D,E
Rationale: Assisting with ambulation, measuring drainage, providing blankets, and escorting family are within UAP scope with proper training. Monitoring IV sites requires nursing judgment and is not delegable.
A transfusion is ordered for a hospitalized client. The charge nurse asks the LPN to start the transfusion. What should the LPN do?
- A. Start the transfusion as ordered
- B. Be sure that dextrose is hanging and then hang the blood
- C. Tell the RN that LPNs are not allowed to hang blood
- D. Hang the blood only if an IV line is already established
Correct Answer: C
Rationale: LPNs typically cannot initiate blood transfusions due to scope of practice limitations, as it requires specialized monitoring, so the LPN should inform the RN.