The nurse participates in the client's resuscitation. Which client assessment data does the nurse determine is an undesirable event during CPR?

Question

1. Bruising over anterior thorax
2. Abdomen becomes distended
3. Client has advanced directive
4. Airway in place without gagging

Answer 1

2
2. Abdominal distention is undesirable during CPR because it is consistent with clin-ical indicators of air in the stomach; this is potentially from esophageal intubation with the endotracheal tube or ventilating the client with an Ambu® bag and airway. Because the distention increases the risk of client aspiration or client expiration, the resuscitation team investigates the distention, verifies endotracheal tube placement, and inserts a nasogastric tube for decompression.
1. Thoracic bruising from chest compressions is usually unavoidable; however, the bruises can upset the family, so the nurse should discuss the bruises with the family to ensure understanding.
3. The health care team welcomes the client's advanced directive to clarify resuscita-tive measures promptly.
4. Maintaining an airway without client gagging is a desirable event during the code because it facilitates client oxygenation and ventilation; however, although this allows for breathing, the code team would rather discontinue the airway with spontaneous client respirations and airway maintenance.