The nurse participates in the patient's resuscitation. Which patient assessment finding does the nurse determine to be an undesirable event during cardiopulmonary resuscitation (CPR)?

Question

a. Bruising is present over the anterior tho-rax.
b. The abdomen has become distended.
c. The patient has an advance directive.
d. An airway is in place without gagging.

Answer 1

B
Abdominal distention is undesirable during CPR because it is consistent with clinical indicators of air in the stomach, which can potentially occur from esophageal intubation with the endotra-cheal tube or ventilating the patient with an Ambu bag and airway. Because distention increases the risk of patient aspiration or expiration, the resuscitation team investigates the distention, veri-fies endotracheal tube placement, and inserts a nasogastric tube for decompression. Thoracic bruising from chest compressions is usually unavoidable; however, since the bruises can upset the family, the nurse should discuss them with the family to ensure understanding. The healthcare team welcomes the patient's advance directive to clarify resuscitative measures promptly. Maintaining an airway without patient gagging is a desirable event during the code because it facilitates patient oxygenation and ventilation. However, although this allows for breathing, the code team would rather discontinue the airway with spontaneous patient respirations and airway maintenance.