A nurse is caring for a patient immediately following a cardiac catheterization with a femoral artery approach. Which action should the nurse take?

Establishing an open airway is the most crucial and immediate action in any respiratory arrest situation, including when a client has heart failure. Here's a detailed explanation: 1. Airway patency is paramount for survival: Oxygen, the essential element for life, cannot reach the lungs and bloodstream without a clear and unobstructed airway. Brain cells are extremely sensitive to oxygen deprivation and start to die within minutes without it, leading to irreversible brain damage or death. 2. Respiratory arrest in heart failure: Heart failure often leads to fluid buildup in the lungs (pulmonary edema), which can significantly impair breathing. Respiratory arrest can occur due to: Excessive fluid accumulation in the lungs. Weakening of respiratory muscles due to fatigue or heart failure itself. Arrhythmias or heart blocks affecting heart's ability to pump effectively. 3. Steps to establish an open airway: Head tilt-chin lift maneuver: Gently tilt the head back and lift the chin to open the airway. Jaw thrust maneuver: If a neck injury is suspected, use the jaw thrust maneuver to avoid further injury. Removal of any visible obstructions: Clear any visible foreign objects or fluids from the mouth or throat. Use of airway adjuncts: Consider using oral or nasal airways to maintain airway patency, especially if the patient is unconscious.

4. Rationale for other choices:

A. Auscultating for breath sounds: While important for assessment, it does not address the immediate need to establish airflow.

C. Establishing IV access: IV access is necessary for medications and fluids, but airway takes priority in respiratory arrest.

D. Feeling for a carotid pulse: Checking for a pulse is essential, but only after ensuring an open airway and attempting to restore breathing.

5. Importance of prioritizing airway: Establishing an open airway allows for potential rescue breaths and ventilation, which can help restore oxygen levels and prevent further deterioration. Even if a pulse is present, without a clear airway, oxygen cannot reach the vital organs, leading to organ failure and death.

Choice A rationale:

It is crucial for the nurse to prioritize patient safety and adhere to professional guidelines when encountering a potential diversion of controlled substances. Informing the charge nurse is the most appropriate initial action for several reasons:

Chain of Command: The charge nurse holds a supervisory position and is responsible for addressing issues within the unit, including concerns about medication diversion. Reporting suspicions to the charge nurse ensures adherence to the established chain of command and facilitates a prompt, organized response.

Confidentiality and Objectivity: The charge nurse is trained to handle sensitive situations discreetly and objectively. They can initiate a thorough investigation while maintaining confidentiality and protecting the rights of all involved parties.

Access to Resources: The charge nurse has access to resources and authority to take immediate action, such as securing medications, initiating patient assessments, and notifying appropriate personnel within the healthcare facility.

Collaboration and Support: The charge nurse can provide guidance and support to the reporting nurse, ensuring their concerns are addressed appropriately and that they feel safe in coming forward with their suspicions.

Rationale for other choices:

B. Reporting the incident directly to the hospital’s security department might be premature without first informing the charge nurse. The charge nurse can assess the situation, gather more information, and determine the most appropriate course of action, which may or may not involve security at this initial stage.

C. Requesting assistive personnel (AP) to monitor the other nurse’s actions is inappropriate. It places a burden on APs who are not trained or authorized to investigate such matters. It could also compromise the integrity of the investigation and potentially jeopardize patient safety.

D. Confronting the other nurse directly is not recommended. It could escalate the situation, create a hostile work environment, and potentially compromise the investigation. It is essential to follow established protocols and involve appropriate personnel to ensure a fair and thorough investigation.