when would chest thrusts be performed in an emergency situation

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. When would chest thrusts be performed in an emergency situation?

A. When performing CPR to initiate cardiovascular circulation.
B. When assessing responsiveness of an unconscious patient.
C. When assisting a pregnant woman who is choking.
D. None of the above examples indicate the need for chest thrusts.

Correct answer: C

Rationale: In the scenario of an emergency where a pregnant woman is choking, chest thrusts are performed to clear the airway obstruction. This technique is used instead of abdominal thrusts to avoid potential harm to the fetus. While chest thrusts are not as effective as abdominal thrusts in clearing obstructions, they are the preferred method in this specific situation. Choices A and B are incorrect as chest thrusts are not typically performed during CPR to initiate cardiovascular circulation or when assessing responsiveness of an unconscious patient. Choice D is incorrect as chest thrusts are indeed warranted when assisting a pregnant woman who is choking.

2. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

A. Listen to a patient's lung sounds for wheezes or rhonchi.
B. Label specimens obtained during percutaneous lung biopsy.
C. Instruct a patient about how to use home spirometry testing.
D. Measure induration at the site of a patient's intradermal skin test.

Correct answer: B

Rationale: Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.

3. Intermittent fevers are:

A. fevers which come and go.
B. fevers which rise and fall but are always considered above the patient's average temperature.
C. fevers which fluctuate more than three degrees and never return to normal.
D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

4. A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?

A. 142/92
B. 118/72
C. 120/80
D. 138/88

Correct answer: A

Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.

5. What is the primary purpose of emergency planning?

A. Comply with the laws of the state.
B. Comply with the laws of the U.S.
C. Comply with both state and U.S. laws
D. Maintain safety

Correct answer: D

Rationale: The primary purpose of emergency planning is to ensure and maintain the safety of people and the preservation of objects, such as buildings and personal possessions during emergencies or disasters. While compliance with state and federal laws regarding emergency planning is important, the main goal is to prioritize life and safety. Choices A, B, and C focus on legal compliance, which is necessary but secondary to the fundamental objective of safeguarding lives and property in emergency situations.