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 verbal communication is crucial during CPR, relying solely on verbal communication may not be sufficient for accurate information exchange, especially in high-stress situations.
B) Correct. CPR teams use both verbal and written communication for a comprehensive understanding of the resuscitation plan. Verbal communication allows for real-time updates, while written communication, such as documentation and checklists, helps ensure critical information is conveyed and understood.
C) Incorrect. Hand signals and nonverbal cues can be valuable additions to communication during CPR, especially in noisy environments or when verbal communication is challenging.
D) Incorrect. While electronic devices can be used for communication, they may not be practical or necessary during CPR. Verbal and written communication are the primary modes of communication in such situations.
Correct Answer is B
Explanation
A) Incorrect. The compression-to-ventilation ratio of 5:1 is not the current guideline for adult CPR. The correct ratio involves more frequent compressions.
B) Correct. The recommended compression-to-ventilation ratio for adult CPR is 30:2. This means 30 chest compressions followed by 2 rescue breaths.
C) Incorrect. Continuous compressions without providing ventilations can lead to inadequate oxygenation, which is essential for the survival of the individual.
D) Incorrect. The compression-to-ventilation ratio of 10:1 is not the current guideline for adult CPR. The correct ratio involves more frequent compressions and periodic rescue breaths.
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