Which of the following action should a nurse take first when caring for a patient with cardiac arrest?

WCL Staff Nurse - 2019

Medical & Surgical Nursing

Medium

Appeared in: WCL Staff Nurse - 2019

Explanation

According to Basic Life Support (BLS) guidelines, the priority sequence for CPR is C-A-B (Compressions, Airway, Breathing).
While starting chest compressions is the absolute first action, it is not provided as an option in this question.
Among the given choices, establishing the airway is the next critical step in the BLS sequence after initiating compressions.
Actions like IV access and cardiac monitoring are part of Advanced Cardiovascular Life Support (ACLS) and should not delay the fundamental steps of BLS.

Option A: Initiating cardiac monitoring is an ACLS intervention. While crucial for rhythm analysis and defibrillation, it should not delay the immediate BLS actions of compressions and airway management.
Option B: Providing intravenous (IV) or intraosseous (IO) access is a key part of ACLS for medication administration. It is a secondary action that must not delay the initiation of CPR.
Option D: A pulse oximeter is ineffective and unreliable during cardiac arrest because there is no adequate peripheral blood flow (perfusion) to generate a reading. Attempting to get a reading is a waste of critical time.

Clinical Relevance

Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Prioritization of nursing actions during cardiac arrest based on Basic Life Support (BLS) guidelines in acute care settings.
The primary principle in cardiac arrest is 'compressions first, compressions fast, compressions hard'. Any action that delays or interrupts chest compressions reduces the chance of survival.
A nurse's immediate recognition of cardiac arrest and initiation of the BLS sequence are critical links in the 'Chain of Survival'.
What if the patient was found unresponsive with a pulse but not breathing (respiratory arrest)? In that case, the priority would be to provide rescue breaths (1 breath every 6 seconds) and not to start chest compressions. This highlights the importance of the initial assessment (checking for breathing and pulse simultaneously).

How to Approach the Question

First, identify the question type. This is a priority-setting question asking for the 'first' action in a clinical emergency.
Recall the established protocol for this emergency. For cardiac arrest, this is the BLS/ACLS algorithm, specifically the C-A-B sequence.
Analyze the options provided. Notice that the absolute highest priority action (starting chest compressions) is missing.
When the top priority action is not an option, select the next highest priority from the sequence. In the C-A-B sequence, 'Airway' is the next step after 'Compressions'.
Eliminate options that are part of later, more advanced interventions (like IV access, monitoring) or are inappropriate for the clinical situation (like pulse oximetry in cardiac arrest).

Concept Tested & Keywords

Concept Tested: Prioritization of nursing actions during cardiac arrest based on Basic Life Support (BLS) guidelines.
Stem keywords: nurse, first, caring, patient, cardiac arrest
Lead-in keywords: first

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