Nokea
When two rescuers perform CPR on an adult, what is the ratio of compressions to ventilations?
- A. 30 compressions to 2 breaths
- B. 10 compressions to 1 breath
- C. 1 compression for each breath
- D. 1 compression to 5 breaths
Correct Answer: A
Rationale: Two-rescuer adult CPR uses a 30:2 ratio to balance circulation and oxygenation.
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The nurse identifies the concept of tissue perfusion as a client problem. Which is an antecedent of tissue perfusion?
- A. The client has a history of coronary artery disease (CAD).
- B. The client has a history of diabetes insipidus (DI).
- C. The client has a history of chronic obstructive pulmonary disease (COPD).
- D. The client has a history of multiple fractures from a motor-vehicle accident.
Correct Answer: A
Rationale: CAD (A) directly impairs cardiac perfusion due to atherosclerosis, an antecedent to perfusion issues. DI (B), COPD (C), and fractures (D) are less directly related.
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?
- A. Instruct the UAP to stop encouraging the leg movements.
- B. Report this behavior to the charge nurse as soon as possible.
- C. Praise the UAP for encouraging the client to move the legs.
- D. Take no action concerning the UAP's behavior.
Correct Answer: C
Rationale: Leg movements (C) prevent DVT in MI patients on bedrest, so praising the UAP is appropriate. Stopping (A), reporting (B), or ignoring (D) are incorrect.
The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching?
- A. Be sure to allow for uninterrupted rest and sleep.
- B. Refer the client to outpatient occupational therapy.
- C. Maintain oxygen via nasal cannula at two (2) L/min.
- D. Discuss upcoming valve replacement surgery.
Correct Answer: A
Rationale: Rest and sleep (A) reduce cardiac demand in pericarditis. Occupational therapy (B), oxygen (C), and valve surgery (D) are not indicated.
The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?
- A. Instruct the client to keep a diary of activity, especially when having chest pain.
- B. Discuss the need to remove the Holter monitor during a.m. care and showering.
- C. Explain that all medications should be withheld while wearing a Holter monitor.
- D. Teach the client the importance of decreasing activity while wearing the monitor.
Correct Answer: A
Rationale: A diary (A) correlates symptoms with ECG changes on the Holter monitor. Removal (B) is incorrect, medications (C) continue, and decreasing activity (D) is unnecessary.
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?
- A. Notify the health care provider.
- B. Call a rapid response team (RRT).
- C. Determine the telemetry monitor reading.
- D. Push the Code Blue button.
Correct Answer: D
Rationale: No pulse/respirations indicate cardiac arrest; pushing the Code Blue button (D) initiates the code team. Notifying HCP (A), RRT (B), or checking telemetry (C) delay resuscitation.