A client collapses while ambulating in the hallway. The nurse calls for help after verifying that the client is not breathing and has no palpable pulse. Which intervention should the nurse implement?
Begin chest compressions at a depth of at least 2 in (5.1 cm).
Perform forceful sternal rub to check for unresponsiveness.
Assess the client for any obvious injuries due to the sudden fall.
Remove the client's clothes and apply automated external defibrillator (AED) pads to chest.
The Correct Answer is A
A. Begin chest compressions at a depth of at least 2 in (5.1 cm): Initiating high-quality chest compressions immediately is the priority in a pulseless and non-breathing client. This promotes circulation of oxygenated blood to vital organs, and improves chances of survival until defibrillation or advanced care is available.
B. Perform forceful sternal rub to check for unresponsiveness: A sternal rub is used to assess responsiveness, but it is unnecessary once the client is confirmed to be unresponsive, pulseless, and not breathing. Delaying compressions could reduce survival chances.
C. Assess the client for any obvious injuries due to the sudden fall: While it is important to note injuries, it is not the immediate priority in a client without a pulse or respirations. Life-saving measures such as CPR should take precedence over secondary assessments.
D. Remove the client's clothes and apply automated external defibrillator (AED) pads to chest: Applying the AED is a critical step but should follow the immediate initiation of chest compressions. If another responder is present, tasks can be divided, but CPR should not be delayed for AED pad placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Contact the client's healthcare power of attorney: This is appropriate if the client is unable to make decisions or if end-of-life care planning is being addressed. However, the client is alert enough to report syncopal episodes, and the priority is stabilizing his condition.
B. Call for immediate help from the rapid response team (RRT): The rapid response team is called for acute, life-threatening changes in clinical. Although the client is tachycardic, there is no indication of immediate decompensation requiring emergency intervention.
C. Report the client’s falls and bruises to adult protective services: The presence of bruises alone is not sufficient to trigger a report without further assessment. These bruises may be related to the syncopal events. The nurse must first assess and stabilize the client.
D. Monitor the client’s blood pressure and oxygen saturation: With atrial fibrillation and a rapid ventricular response, the client is at risk for hemodynamic instability. Monitoring vital signs helps determine whether the high heart rate is compromising perfusion or oxygenation, guiding the urgency of treatment and further evaluation.
Correct Answer is B
Explanation
A. Keep nitroglycerin in a light-colored plastic bottle and readily available: Nitroglycerin should be stored in its original dark glass container to protect it from light, heat, and moisture, all of which can reduce its potency.
B. Avoid isometric exercises, but walk regularly: Isometric exercises can sharply increase blood pressure and cardiac workload, potentially triggering angina. In contrast, regular walking improves cardiovascular health without the abrupt rise in myocardial oxygen demand.
C. Walk briskly in cold weather to increase cardiac output: Cold weather causes vasoconstriction, which increases cardiac workload and can provoke angina. Brisk walking in such conditions is risky for clients with coronary artery disease and should be avoided.
D. Engage in physical exercise immediately after eating to help decrease cholesterol levels: Exercising immediately after a meal diverts blood away from digestion, which can strain the heart and trigger angina. Exercise should be scheduled at least 1–2 hours after meals to avoid postprandial angina.
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