A client asks a nurse about the appropriate first step when recognizing cardiac arrest. What is the nurse's best response?
"The first step in recognizing cardiac arrest is to assess the client's level of responsiveness."
"The first step in recognizing cardiac arrest is to check for signs of cyanosis on the skin."
"The first step in recognizing cardiac arrest is to ask the client if they are experiencing chest pain."
"The first step in recognizing cardiac arrest is to determine the client's blood pressure reading."
The Correct Answer is A
A) Correct. The first step in recognizing cardiac arrest is to assess the client's level of responsiveness. If the client is unresponsive, the nurse should proceed with assessing for the absence of breathing and a pulse.
B) Incorrect. While cyanosis may be a sign of decreased oxygenation, it is not the first step in recognizing cardiac arrest. Assessing responsiveness is the primary step.
C) Incorrect. Asking about chest pain may be important in assessing other cardiac conditions, but it is not the first step in recognizing cardiac arrest.
D) Incorrect. Determining the client's blood pressure reading is not the first step in recognizing cardiac arrest. Assessing responsiveness is the initial priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. The absence of a pulse is the most reliable indicator of cardiac arrest. In cardiac arrest, the heart is no longer pumping effectively, leading to the absence of a palpable pulse.
B) Incorrect. An irregular breathing pattern may be observed in various medical conditions, including respiratory distress, but it is not as definitive as the absence of a pulse in indicating cardiac arrest.
C) Incorrect. Cyanosis of the lips and fingertips can occur in various situations, such as respiratory failure or decreased oxygenation, but it is not specific to cardiac arrest.
D) Incorrect. Sudden loss of consciousness can occur due to various reasons, including seizures or fainting, and is not solely indicative of cardiac arrest.
Correct Answer is D
Explanation
A) Incorrect. While medications are important in advanced cardiac life support, the primary goal of early recognition and response is not the immediate administration of medications.
B) Incorrect. While transporting the client to a specialized cardiac care facility is necessary for some patients, it is not the primary goal of early recognition and response.
C) Incorrect. Advanced airway management and oxygen support are important in the resuscitation process, but the primary goal at the early stage is not advanced airway management.
D) Correct. The primary goal of early recognition and response in cardiac arrest situations is to start immediate chest compressions and deliver rescue breaths to support circulation and oxygenation. These interventions are essential to maintaining blood flow and oxygen delivery to vital organs until advanced medical support is available.
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