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 B
Explanation
A) Incorrect. While providing regular breaks for team members is important, it is not the primary purpose of closed-loop communication during CPR.
B) Correct. The primary purpose of closed-loop communication in a CPR team is to ensure that team members understand their roles and responsibilities clearly. It involves repeating back and confirming instructions to promote effective teamwork and prevent errors.
C) Incorrect. Closed-loop communication primarily focuses on intra-team communication to coordinate resuscitation efforts efficiently. Informing bystanders is important, but it is not the primary purpose of closed-loop communication.
D) Incorrect. Reporting resuscitation outcomes to the hospital administration is not the primary purpose of closed-loop communication during CPR. Its focus is on effective communication within the resuscitation team.
Correct Answer is A
Explanation
A) Correct. The recommended compression-to-ventilation ratio for adult CPR is 30:2. This means 30 chest compressions followed by 2 rescue breaths.
B) Incorrect. Continuous compressions without providing ventilations can lead to inadequate oxygenation, which is essential for the survival of the individual.
C) Incorrect. The ratio of 15:2 is not the current guideline for adult CPR. The correct ratio is 30:2.
D) Incorrect. The compression-to-ventilation ratio in adult CPR is not based on the individual's weight but follows the standard 30:2 guideline.
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