Physiological Adaptation Q 47
Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse’s next action?
A. Call for help and note the time
B. Clear the airway
C. Give two sharp thumps to the precordium and check the pulse
D. Administer two quick blows
Correct Answer: A. Call for help and note the time
Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, or if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedures.
Option B: A patent airway has been established the moment the nurse declares that the client is unconscious and calls for help.
Option C: This action can be done if there is an unwitnessed, unmonitored, unstable ventricular tachycardia when a defibrillator is not immediately available.
Option D: Administering two quick blows to the precordium is less effective and its use is more limited ideally.