A nurse enters a client’s room to discover that the client has no pulse or respirations.
After calling for help, the first action the nurse should take is:
- A- Start a peripheral IV
- B- Initiate high-quality chest compressions
- C- Establish an airway
- D- Obtain the crash cart
The first action the nurse should take after calling for help in this situation is: B. Initiate high-quality chest compressions.
Here's why:
- Time is critical:
When a person has no pulse or respirations, they are in cardiac arrest and lack blood flow to vital organs. Every second counts, and starting chest compressions immediately is crucial to prevent irreversible damage.
- Other actions follow compression:
While establishing an airway and obtaining the crash cart are both important steps, they should not delay the initiation of chest compressions. The American Heart Association and other guidelines recommend starting chest compressions within 10 seconds of recognizing cardiac arrest.
- Chest compressions can restore circulation:
High-quality chest compressions help maintain blood flow to the heart and brain, buying time until other interventions like defibrillation and medication can be implemented.
Therefore, prompt initiation of chest compressions is the highest priority in this emergency situation. The nurse should call for help and then immediately begin chest compressions while also preparing for other necessary interventions.
Procedural order:
Here's the recommended order of actions according to the American Heart Association's Basic Life Support guidelines:
- Recognize cardiac arrest: Assess the patient for responsiveness, breathing, and pulse.
- Call for help: Activate the emergency medical system (EMS) immediately.
- Start chest compressions: Begin high-quality chest compressions without any delay.
- Open the airway: Tilt the head and lift the chin to open the airway.
- Deliver rescue breaths (if trained): If trained and confident, provide two rescue breaths after every 30 chest compressions.
- Defibrillate (if available): If an AED is readily available, use it according to the device instructions.
- Continue CPR: Continue chest compressions and rescue breaths (if trained) until emergency medical services arrive and take over.
Remember, time is of the essence in cardiac arrest. Prompt recognition and intervention, with emphasis on immediate chest compressions, can significantly improve the chances of survival.
