1. The nurse on the day shift walks into a client’s room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?
a) Open the airway.
b) Give the client oxygen.
c) Start chest compressions.
d) Ventilate with a mouth-to-mask device.
2. The nurse witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method?
a) Flexed position
b) Head tilt–chin lift
c) Jaw thrust maneuver
d) Modified head tilt–chin lift
3. The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider (HCP)?
a) One breath should be given for every five compressions.
b) Two breaths should be given for every 15 compressions.
c) Initially, two quick breaths should be given as rapidly as possible.
d) Each rescue breath should be given over 1 second and should produce a visible chest rise.
4. The nurse attempts to relieve an airway obstruction in a 3-year-old conscious child. The nurse performs the abdominal thrust maneuver correctly by standing behind the child, placing her arms under the child’s axillae and around the child, and positioning her hands to deliver the thrusts between which areas?
a) Groin and the abdomen
b) Umbilicus and the groin
c) Lower abdomen and the chest
d) Umbilicus and the xiphoid process
5. The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child?
Nursing Practice Test
Answers and Rationale
- Rationale: The next nursing action would be to start chest compressions. Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim’s airway.
- Test-Taking Strategy: Note the strategic word next . Visualize the steps of cardiopulmonary resuscitation (CPR) to answer the question. Recalling CAB—compressions, airway, breathing—will assist you in answering this question.
- Rationale: If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt–chin lift maneuver 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: Focus on the subject , basic life support measures for the client with a suspected neck injury. Recall the concerns associated with a neck injury. The head tilt–chin lift is not used if there is a suspected neck injury. A flexed position does not open the airway.
- Rationale: In adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. HCPs should employ a 30:2 compression-to-ventilation ratio for the adult victim.
- Test-Taking Strategy: Focus on the subject , rescue breathing. Read each option carefully. Noting the words visible chest rise in the correct option will direct you to this option.
- Rationale: To perform abdominal thrusts on a child, the rescuer stands behind the victim and places the arms directly under the victim’s axillae and around the victim. The rescuer places the thumb side of one fist against the victim’s abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrusts. One must take care not to touch the xiphoid process or the lower margins of the rib cage because force applied to these structures may damage internal organs.
- Test-Taking Strategy: Focus on the subject , abdominal thrust maneuver in the child. Note the age of the child. Consider the anatomical location and the effect of the maneuver in dislodging an obstruction to answer correctly.
- Rationale: In a child between the ages of 1 and 8 years, one breath every 6-8 seconds is delivered.
- Test-Taking Strategy: Focus on the subject , rescue breathing and breaths per second. Note the age of the child. Recalling the normal respiratory rate in a child at this age and focusing on the subject , breaths per second, will assist in directing you to the correct option.
Proceed to the next set of questions:
Nursing Practice Test on Cardiovascular 6-10