Nokea
The nurse is precepting a graduate nurse as they perform resuscitation on an adult with cardiac arrest. Which action by the graduate requires immediate follow-up by the nurse?
- A. Assesses the client’s pulse by palpating the carotid artery.
- B. Allows for chest recoil after every chest compression.
- C. Compresses at a depth of 2 inches on the center breastbone.
- D. Asks for an automated external defibrillator after one cycle of CPR.
Correct Answer: C
Rationale: Compressing at a depth of 2 inches (C) is inadequate for adult CPR, as guidelines require 2.4 inches (6 cm) for effective circulation, requiring immediate correction. Pulse check (A), chest recoil (B), and requesting a defibrillator (D) are correct actions.
You may also like to solve these questions
The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following activities would be appropriate to delegate? Select all that apply.
- A. Performing initial client assessments
- B. Making client beds
- C. Giving clients bed baths
- D. Administering client medications
- E. Ambulating clients
- F. Assisting clients with meals
Correct Answer: B, C, E, F
Rationale: UAPs can make beds (B), give bed baths (C), ambulate clients (E), and assist with meals (F), as these are non-clinical tasks. Initial assessments (A) and medication administration (D) require nursing judgment, reserved for RNs or LPNs.
The nurse manager regularly performs chart audits and room inspections in the unit. They tell the staff to address the unit's deficiencies during a meeting. Which concept of management is the nurse manager displaying?
- A. Benchmarking
- B. Continuous Quality Improvement
- C. Performance Improvement
- D. Quality Management
Correct Answer: B
Rationale: Addressing deficiencies through audits and staff meetings (B) reflects continuous quality improvement, focusing on ongoing process enhancement. Benchmarking (A) compares to external standards, performance improvement (C) is specific to outcomes, and quality management (D) is broader.
The nurse is recommending a change in the healthcare facility's policy and procedure regarding usage of restraint. To ensure that the nurse is providing findings from the highest quality of evidence, the nurse should include information from a
- A. detailed expert opinion.
- B. systematic review.
- C. quantitative study.
- D. qualitative study.
Correct Answer: B
Rationale: Systematic reviews (B) provide the highest quality evidence by synthesizing multiple studies, ideal for policy changes like restraint use. Expert opinions (A), quantitative (C), and qualitative studies (D) are lower in the evidence hierarchy.
The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.
The nurse has been made aware of the following client situations. The nurse should first follow up with the client
- A. receiving a chemotherapy infusion who reports nausea and vomiting.
- B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain.
- C. being treated for aplastic anemia and has a temperature of 101.1°F (38.4°C).
- D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.
Correct Answer: C
Rationale: A fever in a client with aplastic anemia (C) indicates potential infection, a life-threatening complication due to low white blood cells, requiring immediate attention. Nausea from chemotherapy (A), hematuria with kidney disease (B), and TB with a mask (D) are less urgent.