You are on duty in the emergency department (ED) when a "code blue" is called. As the code nurse, you
grab the crash cart and run to the code, which is in the employee lounge of the operating room.
On the
couch, you find a nurse, Z.H., unconscious, dusky, and barely breathing.
What immediate assessment of Z.H. do you need to perform?
The initial assessment focuses on the CABs (circulation, airway, breathing). Is her airway patent?
Measure respiratory rate and oxygen saturation. Check for any signs of aspiration. Assess respiratory
effort and auscultate lung sounds. Obtain her pulse and blood pressure. Note skin color and warmth.
Quickly survey her neurologic status; check for signs of any injury.
You might also like to view...
A 31-year-old client with a diagnosis of end-stage liver failure has been admitted to the intensive care unit of a hospital
Arterial blood sampling indicates that the man has an acid-base imbalance. Which of the following situations is most likely to result in an inappropriate pH? A) Conservation or formation of new HCO3- by the kidneys B) Low albumin and plasma globulin levels C) Transcompartmental exchange of H+ and potassium ions D) Renal excretion of HCO3- in the presence of excess base
Which statement is true about defense mechanisms?
a. They are universal. b. The use of defense mechanisms usually indicates pathology. c. Most defense mechanisms operate at the conscious level. d. Persons should learn how to avoid using defense mechanisms.
The client is prescribed 1,000 mL NS IV to infuse over 24 h. How many mL/hr will this client receive? Round to the nearest whole number
What will be an ideal response?
The client complains of blurred vision after taking the eye drops. What does the nurse implement first?
1. Withholds the client's ophthalmic drops 2. Warms the eye drops for subsequent doses 3. Notifies the ophthalmologist of the findings 4. Asks the client questions to clarify "blurred"