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 C
Explanation
Rationale for Choice A:
Refer Questions to the Nursing Supervisor:
While it's essential to involve the nursing supervisor in situations that require their expertise or authority, it's not always necessary for basic inquiries about a patient's presence on the unit.
Disadvantages of referring calls to the nursing supervisor in this scenario:
It could delay the dissemination of essential information to concerned colleagues.
It could increase the workload of the nursing supervisor, potentially diverting their attention from more critical tasks. It could create a perception of a lack of transparency or openness among staff members.
Rationale for Choice B:
Transfer calls directly to the patient’s room:
Transferring calls directly to a patient's room without their consent breaches their privacy and confidentiality. It could also place undue stress on the patient, especially if they are not prepared to receive calls or discuss their health status.
Disadvantages of transferring calls directly to the patient’s room:
It violates the patient's right to privacy and confidentiality. It could disrupt the patient's rest and recovery.
It could place the patient in an uncomfortable position of having to answer questions about their health when they may not feel ready to do so.
Rationale for Choice C:
Acknowledge that the person is a patient on the unit, but give no specific details about the patient’s condition:
This approach strikes a balance between protecting the patient's privacy and providing necessary information to concerned colleagues. It verifies the patient's presence on the unit without disclosing any sensitive details about their health, thus adhering to ethical and legal guidelines.
Advantages of acknowledging the patient’s presence without providing details:
Respects the patient's right to privacy and confidentiality. Aligns with ethical and legal principles of healthcare.
Provides basic information to concerned colleagues without compromising patient information. Helps to establish trust and transparency among staff members.
Rationale for Choice D:
Contact the patient’s provider:
Contacting the patient's provider for every inquiry about the patient's presence is not practical or efficient. It could overburden the provider and delay the relay of information to concerned colleagues.
Correct Answer is C
Explanation
Choice A rationale:
This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.
It's important to validate the patient's experience and offer support, even if the pain level is not severe.
This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.
Choice B rationale:
This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.
Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.
Choice C rationale:
This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.
It is important to rule out any underlying medical conditions that may be causing the pain.
This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.
Choice D rationale:
This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.
This could lead to the patient feeling anxious or worried about their health.
It is important to investigate the cause of the pain before making any assumptions.
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