A nurse is assessing an unresponsive client and determines the client is not breathing and has no pulse. What is the nurse's immediate action?
"Activate the emergency response system and retrieve the automated external defibrillator (AED)."
"Begin chest compressions at a rate of 60 compressions per minute."
"Administer two rescue breaths followed by 10 seconds of pulse check."
"Wait for additional healthcare providers to arrive before starting any interventions."
The Correct Answer is A
A) Correct. In the event of an unresponsive individual with no breathing and no pulse, the nurse's immediate action is to activate the emergency response system and retrieve the AED. Early access to the AED can significantly improve the chances of survival for the client in case they are experiencing a shockable rhythm.
B) Incorrect. Chest compressions should be started immediately after identifying an unresponsive individual with no pulse. The rate of compressions should be 100 to 120 compressions per minute, not 60.
C) Incorrect. The current guidelines recommend starting with chest compressions, not rescue breaths, when assessing an unresponsive individual without a pulse.
D) Incorrect. Time is critical during a cardiac arrest, and the nurse should not wait for additional healthcare providers before initiating CPR and activating the emergency response system.
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Related Questions
Correct Answer is A
Explanation
A) Correct. In the event of an unresponsive individual with no breathing and no pulse, the nurse's immediate action is to activate the emergency response system and retrieve the AED. Early access to the AED can significantly improve the chances of survival for the client in case they are experiencing a shockable rhythm.
B) Incorrect. Chest compressions should be started immediately after identifying an unresponsive individual with no pulse. The rate of compressions should be 100 to 120 compressions per minute, not 60.
C) Incorrect. The current guidelines recommend starting with chest compressions, not rescue breaths, when assessing an unresponsive individual without a pulse.
D) Incorrect. Time is critical during a cardiac arrest, and the nurse should not wait for additional healthcare providers before initiating CPR and activating the emergency response system.
Correct Answer is D
Explanation
A) Incorrect. Defibrillation is used to stop abnormal heart rhythms, but it is not intended to restore a pulse directly. Effective CPR and defibrillation work together to improve the chances of restoring circulation.
B) Incorrect. While defibrillation can stop certain abnormal heart rhythms, it does not address all cardiac arrest situations.
C) Incorrect. Defibrillation is not used to relieve pain or discomfort. Its primary purpose is to restore a normal heart rhythm.
D) Correct. Early defibrillation is crucial because it helps to reset the heart's electrical activity, allowing the heart to resume an effective rhythm. The sooner defibrillation is performed, the better the chances of restoring a normal heart rhythm and improving the chances of survival.
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