The nurse walks into a male client's room and finds him on the floor with his eyes closed. Which should the nurse implement first?

Question

1. Initiate cardiac compressions.
2. Call for a code from the room.
3. Help client back into the bed.
4. Verify client unresponsiveness.

Answer 1

4
4. The nurse should assess the client for unresponsiveness by touching the client and shouting "Are you okay?" before activating a code. Although unresponsiveness can be caused by many factors, the nurse wants to stimulate the client and improve breathing first, if possible.
1. The nurse avoids initiating chest compressions until assessing for a pulse because chest compressions over a beating heart can precipitate arrhythmias.
2. Research by the American Heart Association recommends that first responders ve-rify unresponsiveness before initiating any resuscitative measures because if the client is responsive, the code can be unnecessary.
3. The nurse establishes unresponsiveness before thinking about putting the client into bed to complete a proper client assessment for the situation; besides, the nurse should not move the client until the spine is cleared. The nurse is not aware of why the client is on the floor, so the must treat the client as though he had a spinal injury until it is eliminated.