Emergency Response And CPR Participation
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NCLEX-PN › Emergency Response And CPR Participation
A 70-year-old client with diabetes is in a skilled nursing facility and suddenly becomes unresponsive while ambulating; the LPN finds no pulse and no breathing. Which step is PRIORITY in this situation?
Initiate CPR and send someone to activate the emergency response system and obtain the AED
Place the client in recovery position and monitor for spontaneous breathing
Check the client’s capillary blood glucose level and administer oral glucose
Call the family to report the change in condition and request advance directive paperwork
Explanation
This question tests knowledge of emergency response and CPR participation in diabetic client arrest. The priority framework is the ABCs, initiating CPR for no pulse or breathing. Initiating CPR and activating response with AED is the highest priority despite diabetes history. Checking glucose (B) delays, recovery position (C) assumes breathing, and calling family (D) is non-urgent. The decision-making principle is treating as arrest unless proven otherwise. Etiology secondary to CPR. A transferable strategy is to start CPR in unresponsive pulseless clients regardless of comorbidities.
A 19-year-old client with a severe latex allergy is in an outpatient clinic and develops sudden wheezing and throat swelling after contact with latex gloves; blood pressure is 82/44 mm Hg, heart rate 138/min, and oxygen saturation 87%. Which step is PRIORITY in this situation?
Administer intramuscular epinephrine per emergency protocol and activate emergency response
Remove the latex gloves and observe the client for 30 minutes for symptom resolution
Call the provider to request an order for a corticosteroid
Obtain a peak flow reading and document the value before intervening
Explanation
This question tests knowledge of emergency response and CPR participation in latex anaphylaxis. The priority framework is immediate safety, treating with epinephrine. Administering IM epinephrine and activating response is the highest priority for airway and shock. Removing gloves (B) is insufficient, peak flow (C) delays, and requesting steroid (D) is slower. The decision-making principle is epinephrine for severe allergy symptoms. Stay with client. A transferable strategy is to avoid triggers but treat exposures aggressively with protocols.
A 45-year-old client receiving intravenous antibiotics reports sudden itching and throat tightness; within minutes the LPN notes wheezing, stridor, facial swelling, hives, blood pressure 78/40 mm Hg, heart rate 132/min, and oxygen saturation 86%. What is the nurse's FIRST action in this emergency?
Notify the provider and wait for an order for an antihistamine
Apply a warm blanket and elevate the legs, then reassess blood pressure in 15 minutes
Stop the infusion and administer intramuscular epinephrine per emergency protocol while calling for help
Obtain a complete allergy history and document the reaction before intervening
Explanation
This question tests knowledge of emergency response and CPR participation in anaphylaxis during IV antibiotics. The priority framework is immediate safety, focusing on stopping the allergen and treating shock. Stopping the infusion and administering IM epinephrine per protocol while calling for help is the highest priority to reverse bronchospasm and hypotension. Notifying for antihistamine (B) delays, obtaining history (C) is post-stabilization, and applying blanket (D) ignores airway. The decision-making principle is recognizing anaphylaxis signs requiring epinephrine as first-line. Prompt action prevents progression to arrest. A transferable strategy is to always have epinephrine ready for suspected allergic reactions and activate help immediately.
A 72-year-old client in a rehabilitation facility suddenly clutches the throat while eating, cannot speak, has a weak ineffective cough, and becomes cyanotic; oxygen saturation is 76% and the client is alert but panicked. What is the nurse's FIRST action in this emergency?
Call the provider for an order for a chest x-ray and keep the client NPO
Give the client water to help wash down the food bolus
Perform abdominal thrusts until the obstruction is relieved or the client becomes unresponsive
Encourage the client to cough and obtain a full set of vital signs
Explanation
This question tests knowledge of emergency response and CPR participation in choking with airway obstruction. The priority framework is immediate safety, using abdominal thrusts for conscious choking. Performing abdominal thrusts until relieved or unresponsive is the highest priority to dislodge the obstruction. Giving water (B) worsens obstruction, encouraging cough (C) is for mild cases, and calling for x-ray (D) delays. The decision-making principle is the universal choking sign indicating severe blockage needing thrusts. Continue until effective or CPR needed. A transferable strategy is to assess cough effectiveness before intervening in choking incidents.
A 74-year-old client admitted for pneumonia suddenly becomes unresponsive while sitting in a chair; the LPN notes absent chest rise, agonal gasps, and no palpable carotid pulse. Which intervention should the nurse implement IMMEDIATELY?
Place the client in high Fowler position and encourage deep breathing
Obtain a full set of vital signs and notify the provider of the change in condition
Delegate a staff member to suction the airway and wait for the code team to arrive
Start chest compressions at the recommended rate and depth while calling for help
Explanation
This question tests knowledge of emergency response and CPR participation for sudden unresponsiveness in a client with pneumonia. The priority framework is the ABCs, focusing on immediate circulation support when pulse is absent. Starting chest compressions at the recommended rate and depth while calling for help is the highest priority to maintain perfusion in cardiac arrest. Placing in high Fowler position (B) is inappropriate for arrest, obtaining vital signs (C) delays intervention, and delegating suctioning (D) assumes the code team without starting CPR. The decision-making principle is to initiate CPR immediately upon confirming no pulse and abnormal breathing. Agonal gasps indicate arrest, not effective respiration. A transferable strategy is to prioritize compressions over other actions in pulseless clients to buy time for advanced care.
A 40-year-old client with a history of opioid use is found in the outpatient restroom with pinpoint pupils, respirations 4/min and shallow, oxygen saturation 70%, heart rate 58/min, and the client is difficult to arouse but has a palpable pulse. Which intervention should the nurse implement IMMEDIATELY?
Ask a staff member to search the client’s belongings for medication bottles
Obtain a full set of vital signs and complete a neurologic assessment
Place the client in a supine position and wait for the provider to prescribe an antidote
Call for emergency assistance and begin rescue breathing or bag-valve-mask ventilation with oxygen as available
Explanation
This question tests knowledge of emergency response and CPR participation in opioid overdose. The priority framework is the ABCs, supporting breathing in respiratory depression. Calling for assistance and beginning rescue breathing is the highest priority to correct hypoxia. Obtaining vitals (B) delays, waiting for antidote (C) risks arrest, and searching belongings (D) is unethical. The decision-making principle is providing ventilation if pulse present but breathing inadequate. Naloxone may follow but breathing first. A transferable strategy is to suspect overdose in pinpoint pupils and bradypnea, prioritizing airway support.
A 50-year-old client in the emergency department suddenly becomes unresponsive; the LPN notes no chest rise and cannot detect a pulse within 10 seconds. What should the nurse do NEXT after recognizing cardiac arrest?
Obtain a 12-lead electrocardiogram and notify the provider of the rhythm
Insert an oral airway and suction secretions before starting compressions
Check the client’s temperature and apply warm blankets
Start CPR and direct someone to activate the code and bring the AED
Explanation
This question tests knowledge of emergency response and CPR participation in ED arrest. The priority framework is the ABCs, starting CPR promptly. Starting CPR and directing for code and AED is the highest priority after confirmation. Inserting airway (B) is advanced, obtaining ECG (C) delays, and checking temperature (D) is irrelevant. The decision-making principle is immediate compressions in no pulse. Team response follows. A transferable strategy is to reassess pulse quickly but act on absence in unresponsiveness.
A 48-year-old client on a telemetry unit suddenly becomes unresponsive; the LPN notes no breathing and no palpable carotid pulse. The nurse begins CPR and another staff member brings the AED. Which step is PRIORITY when the AED is ready to analyze the rhythm?
Remove the AED pads to quickly check for a pulse before analysis
Ask a nursing assistant to hold the client’s shoulders steady during analysis
Ensure no one is touching the client while the AED analyzes and during any shock delivery
Continue compressions while the AED analyzes to avoid any pause in CPR
Explanation
This question tests knowledge of emergency response and CPR participation during AED analysis. The priority framework is safety during defibrillation to avoid harm. Ensuring no one touches the client during analysis and shock is the highest priority for effective AED use. Continuing compressions (B) interferes, removing pads (C) counterproductive, and holding shoulders (D) unsafe. The decision-making principle is clearing the area for analysis. Resume CPR post-shock. A transferable strategy is to verbalize 'clear' loudly before AED functions in all settings.
A 36-year-old client receiving a new intravenous medication suddenly develops hives, audible wheezing, and difficulty swallowing; blood pressure is 76/38 mm Hg and heart rate is 150/min. Which intervention should the nurse implement IMMEDIATELY?
Administer intramuscular epinephrine per protocol and maintain airway while calling for emergency assistance
Obtain a detailed medication history and document the suspected allergy
Request an order for oral diphenhydramine and reassess in 30 minutes
Pause the medication and restart it slowly once the rash begins to fade
Explanation
This question tests knowledge of emergency response and CPR participation in medication anaphylaxis. The priority framework is immediate safety, using epinephrine for symptoms. Administering IM epinephrine and maintaining airway is the highest priority while calling help. Pausing medication (B) insufficient, history (C) post-care, and requesting diphenhydramine (D) secondary. The decision-making principle is recognizing anaphylaxis needing urgent reversal. Monitor vitals. A transferable strategy is to observe closely during new medication administration for reactions.
A 33-year-old client with a known peanut allergy is eating in a long-term care dining room and suddenly develops hoarseness, swelling of the lips, widespread hives, and difficulty breathing; vital signs are blood pressure 84/50 mm Hg, heart rate 140/min, respiratory rate 30/min, oxygen saturation 88%. Which intervention should the nurse implement IMMEDIATELY?
Offer sips of water and position the client flat to prevent fainting
Give an oral antihistamine and reassess for improvement over the next 30 minutes
Ask a nursing assistant to obtain vital signs every 5 minutes while the nurse calls the family
Administer intramuscular epinephrine to the outer thigh per facility protocol and stay with the client
Explanation
This question tests knowledge of emergency response and CPR participation in anaphylaxis from peanut allergy. The priority framework is the ABCs, prioritizing airway and circulation in shock. Administering IM epinephrine per protocol and staying with the client is the highest priority to counteract histamine effects and monitor. Offering water (B) risks aspiration, delegating vitals (C) abandons the client, and giving antihistamine (D) is slower-acting. The decision-making principle involves immediate epinephrine for systemic symptoms. Monitoring prevents biphasic reaction. A transferable strategy is to treat any swelling with breathing difficulty as anaphylaxis needing urgent epinephrine.