Which of the following actions is to be performed by the nurse after the restoration of spontaneous ventilati… - RUHS, Jaipur, M.Sc Nursing Entrance Exam-2022

RUHS, Jaipur, M.Sc Nursing Entrance Exam-2022

Nursing Foundation

Medium

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2022

Explanation

In Basic Life Support (BLS), once a patient has a return of spontaneous circulation (has a pulse) and is breathing normally but remains unresponsive, the correct action is to place them in the recovery position.
The primary purpose of the recovery position is to maintain a patent (open) airway.
It uses gravity to prevent the tongue from falling back and obstructing the throat, and it allows any fluids like saliva or vomit to drain safely out of the mouth, reducing the risk of aspiration (inhaling foreign material into the lungs).

Option A: Chest compressions are performed on a patient who has no pulse. Continuing compressions after circulation has been restored is unnecessary and can cause significant injury, such as rib fractures or damage to internal organs.
Option C: While transferring the patient to a hospital is a crucial next step for definitive care, it is not the most immediate action. The priority is to ensure the patient's airway is protected at the scene before and during transport.
Option D: Intubation (placing a breathing tube) is an advanced airway management technique that is part of Advanced Life Support (ALS), not BLS. It is also not necessary if the patient is breathing spontaneously and effectively on their own.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Post-resuscitation care in Basic Life Support (BLS) in the correct sequence, documenting the action clearly, and monitoring for the expected response.
The recovery position is a simple yet life-saving maneuver that any nurse or first responder can perform without equipment. It is a fundamental skill to prevent airway obstruction and aspiration, which are common and preventable causes of death in unconscious individuals.
Nurses must continuously monitor a patient in the recovery position for any changes in breathing. The patient is not considered fully stable until they regain consciousness.
What if? If the patient in the recovery position stops breathing or breathing becomes abnormal (e.g., gasping), the nurse must immediately roll them onto their back and restart CPR, beginning with chest compressions.

How to Approach the Question

First, identify the core of the question: it asks for the immediate action after a patient starts breathing again during BLS.
Recognize the patient's state: 'Restoration of spontaneous ventilation' means the patient is breathing, and since it's a BLS scenario, they are likely still unconscious.
Recall the BLS algorithm. The sequence is Check for response -> Call for help -> Circulation (Compressions) -> Airway -> Breathing. If C, A, and B are restored, the next step is to maintain that state safely.
Evaluate each option against this context. 'Continue chest compression' is incorrect because a pulse has returned. 'Intubation' is an advanced skill (ALS), not BLS. 'Shift to Hospital' is a later step.
Conclude that 'Recovery position' is the only option that addresses the immediate need to protect the airway of an unconscious but breathing patient, which is the priority at this stage of BLS.

Concept Tested & Keywords

Concept Tested: Post-resuscitation care in Basic Life Support (BLS)
Stem keywords: restoration of spontaneous ventilation, basic life support, nurse
Lead-in keywords: actions to be performed