A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?

Appeared in: BHU NO-2019

Explanation

For an adult client, effective chest compressions require depressing the sternum to a depth of at least 2 inches (5 cm) but no more than 2.4 inches (6 cm).
This specific depth is necessary to adequately compress the heart between the sternum and the spine, which generates blood flow to vital organs.
The option '2 to 2 ½ inches' falls squarely within the recommended guidelines for high-quality adult CPR.
Achieving the correct depth at the proper rate (100-120/min) is a critical component of basic life support until a defibrillator can be used.

Option B: A compression depth of ½ to ¾ inch is far too shallow to generate any meaningful blood flow in an adult, child, or infant. It would be completely ineffective.
Option C: A compression depth of 1 to 1 ½ inches (approximately 4 cm) is the recommended depth for infants, not adults.
Option D: A compression depth of ¾ to 1 inch is grossly insufficient for an adult and would not create the necessary intrathoracic pressure for circulation.

Clinical Relevance

Nursing practice connection: Use the key finding related to Adult CPR: Chest Compression Depth to guide bedside assessment, documentation, and the next nursing action.
Performing high-quality chest compressions with the correct depth and rate is the most critical intervention in CPR and directly impacts patient survival and neurological outcome.
Compressions that are too shallow are ineffective, while compressions that are too deep can cause injuries like rib fractures or internal organ damage. Adherence to guidelines is a key patient safety measure.
What if the patient was a child (age 1 to puberty)? The compression depth would change to approximately 2 inches (5 cm), and the nurse could use one or two hands depending on the child's size.

How to Approach the Question

First, identify the key elements of the question: the action (cardiac compression), the patient (adult client), and the specific parameter being asked (depth of depression).
This is a factual recall question based on established clinical guidelines (AHA CPR guidelines).
Recall the standard compression depth for an adult, which is 2 to 2.4 inches (5 to 6 cm).
Evaluate each option against this standard.
Eliminate options that are clearly incorrect: those that are too shallow (B and D) and the one that applies to a different age group (C, for infants).
Select the option that accurately reflects the guideline for adult CPR.

Concept Tested & Keywords

Concept Tested: Adult CPR: Chest Compression Depth
Stem keywords: cardiac compression, adult client, depress the lower sternum, maintain circulation
Lead-in keywords: How far
Negative lead-in flag: false

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 p. 46-48

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 763-765

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 610-612

Practise the full BHU NO-2019

Attempt every question from this paper in a timed mock, then review the full solution for each one.