A critical care nurse finds a postoperative client unresponsive and calls for a code blue. Which of the following next actions should the nurse take?
Retrieve the crash cart
Apply a bag valve mask and provide ventilation
Attach an automatic external defibrillator (AED)
Begin chest compressions
The Correct Answer is D
A. While the crash cart is essential for advanced resuscitation, starting chest compressions takes priority. The nurse should begin CPR immediately while another team member retrieves the cart.
B. Ventilation is important, but chest compressions should be initiated first to maintain circulation and perfusion. Once compressions are underway, airway and breathing support can follow according to the CAB (Circulation, Airway, Breathing) sequence of Basic Life Support (BLS).
C. Attaching the AED is a crucial step, but it should occur after or while chest compressions are in progress, as delays in compressions reduce the chances of survival.
D. This is the first action the nurse should take after confirming unresponsiveness and calling for help. Immediate, high-quality compressions restore blood flow to vital organs and are the priority intervention in cardiac arrest management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A black tag indicates a client who is deceased or expected to die due to catastrophic injuries. These clients receive comfort measures only, as survival is unlikely even with treatment.
B. A yellow tag is for clients with serious but not life-threatening injuries. Treatment can be delayed without immediate risk of death.
C. A green tag indicates minor injuries (often called “walking wounded”). These clients are stable and can wait for care until more urgent cases are treated.
D. A red tag identifies clients who have life-threatening but potentially survivable injuries that require immediate intervention. These clients are the highest priority during triage, as prompt treatment can significantly improve survival outcomes.
Correct Answer is A
Explanation
A. Supporting a client’s wishes to refuse prescribed treatments demonstrates autonomy, which is the ethical principle that respects a client’s right to make their own informed decisions about their care.
B. Ensuring that a client understands expectations for group participation reflects veracity or providing clear information, but does not directly demonstrate autonomy.
C. Describing the adverse effects of medications is part of informed consent and education, supporting autonomy indirectly, but the primary action is information provision.
D. Spending extra time to calm an agitated client reflects beneficence and caring, focusing on the client’s well-being rather than decision-making rights.
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