Published Apr 20, 2014
Guys, today we discussed with our colleague a question from MOSBY 2nd Ed. , p.42, question 134. We had the same answer that was different from the book.
Mr X has been admitted to hospital with CHF. Nurse walks into his room and finds him unresponsive and cyanotic. What is the priority nursing action?
a.call for help
B. assess for breathing
c. adm O2
d. assess for pulse what is your answer and rational?
Your first response when finding a patient cyanotic and unresponsive ALWAYS is to call for help. You can be assessing for breathing and a pulse while you wait for help to arrive. Applying O2 to someone who isn't breathing is a waste of time. It may be appropriate later, but not the very first intervention. The chain of survival is the same within the hospital as it is outside it.
klone, MSN, RN
CAB. Assess pulse first, then call for help.
Actually, I change my answer - ask for help first, once it's been determined that they're unresponsive. That is what you would do with BLS.
Thank you for response. According to MOSBY, Nurse should call for help regardless of the reason. However, all we know is the fact that patient is unresponsive. How the priority changes if patient has Ps and breathing, and his unresponsiveness was caused by hypoglycemia? should the nurse ask for help first?
Yes. The algorithm for an unresponsive person is call for help, assess pulse, assess breathing, perform CPR in the absence of a pulse and so on. If the patient is unresponsive but breathing with a pulse, then you start looking at your H's and T's, which are reversible causes of (impending) cardiac arrest.
How to use the H's and T's
I chose Ps first
Thanks a lot? Janfrn. your link is very helpful.
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