A nurse is caring for a client who has heart failure and respiratory arrest. What should be the nurse’s first action?
Auscultate for breath sounds.
Establish an open airway.
Establish IV access.
Feel for a carotid pulse.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.
Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.
It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.
Rationale for Choice B:
Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.
Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.
Rationale for Choice C:
Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.
While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.
The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:
Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.
Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate
Crackles in the lungs Shortness of breath Hypoxia
Early identification of these signs is crucial for prompt intervention and prevention of serious complications.
Correct Answer is B
Explanation
Choice A rationale:
Malnutrition is a risk factor for HAIs, but it is not a common cause. Malnutrition weakens the immune system, making it less able to fight off infection. However, malnutrition is not directly responsible for the introduction of pathogens into the body, which is a necessary step for the development of an HAI.
Choice C rationale:
Multiple caregivers can contribute to the spread of pathogens, but it is not a common cause of HAIs. When multiple caregivers are involved in a patient's care, there is a greater chance that one of them may be carrying a pathogen and transmit it to the patient. However, this is not the most common way that HAIs are spread.
Choice D rationale:
Chlorhexidine washes are actually used to prevent HAIs, not cause them. Chlorhexidine is an antiseptic that kills bacteria and other pathogens. It is often used to clean the skin before surgery or other invasive procedures.
Choice B rationale:
Urinary catheterization is a common cause of HAIs. A urinary catheter is a tube that is inserted into the bladder to drain urine. Catheters can introduce bacteria into the bladder, which can lead to urinary tract infections (UTIs). UTIs are the most common type of HAI.
Here are some of the reasons why urinary catheterization is a common cause of HAIs:
Catheters can introduce bacteria into the bladder. The catheter itself can act as a conduit for bacteria to enter the bladder. Bacteria can also enter the bladder around the catheter, where the catheter enters the urethra.
Catheters can irritate the bladder. This can make the bladder more susceptible to infection. Catheters can obstruct the flow of urine. This can allow bacteria to grow in the bladder.
Catheters can be difficult to keep clean. This can increase the risk of bacteria growing on the catheter and being introduced into the bladder.
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