Which of the following actions would a nurse take first when caring for a patient experiencing a cardiac arre… - JIPMER Nursing Officer-2017

JIPMER Nursing Officer-2017

Medical Surgical Nursing

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Appeared in: JIPMER Nursing Officer-2017

Explanation

The American Heart Association (AHA) guidelines for Basic Life Support (BLS) prioritize actions in the C-A-B sequence: Chest Compressions, Airway, Breathing.
While initiating high-quality chest compressions is the absolute first intervention in cardiac arrest, it is not listed as an option in this question.
Among the given choices, establishing an open airway is the next step in the C-A-B sequence and therefore the highest priority action to take.
A patent airway is essential for subsequent oxygenation and ventilation; without it, other resuscitation efforts will be ineffective.

Option A: This is an Advanced Cardiovascular Life Support (ACLS) intervention performed after high-quality BLS (compressions and airway) is established.
Option B: This is also an ACLS step for medication administration. It is performed after BLS and often after the first rhythm check/shock.
Option D: A pulse oximeter requires pulsatile blood flow to function. In cardiac arrest, there is no effective circulation, making the device and its readings useless.

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 BLS guidelines in acute care settings.
In a cardiac arrest, immediate and effective BLS significantly increases the chances of survival. The 'compressions-first' approach minimizes interruptions in blood flow to the brain and heart.
Nurses must be able to instantly recognize cardiac arrest and initiate the C-A-B sequence without hesitation, often leading a resuscitation team until advanced help arrives.
What if the patient was a child? The sequence might change. For children, especially infants, if the arrest is likely due to a respiratory issue (asphyxia), the sequence may revert to A-B-C, or rescue breaths might be given first before starting compressions.

How to Approach the Question

Identify the core of the question: It asks for the first action in a life-threatening emergency (cardiac arrest).
Recall the standard protocol for this emergency. For adult cardiac arrest, this is the C-A-B sequence from the American Heart Association (AHA).
List the C-A-B steps mentally: 1. Chest Compressions, 2. Airway, 3. Breathing.
Analyze the given options against this protocol. Notice that the number one priority, Chest Compressions, is missing.
Select the option that represents the next highest priority in the sequence, which is 'Airway'.
Eliminate the other options by recognizing they are later steps in Advanced Cardiovascular Life Support (ACLS) (monitoring, IV access) or ineffective in this specific situation (pulse oximetry).

Concept Tested & Keywords

Concept Tested: Prioritization of nursing actions during cardiac arrest based on BLS guidelines.
Stem keywords: cardiac arrest, nurse, first action
Lead-in keywords: first

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