The nurse cares for a seven year old client who is pulseless. After calling a code blue, the nurse should take which action?
The nurse cares for a seven year old client who is pulseless. After calling a code blue, the nurse should take which action?
A. Give 2 minutes of CPR at a compression-ventilation ratio of 15:2.
[27%]
B. Leave the client to retrieve an automatic external defibrillator (AED), then start CPR at a compression-ventilation ratio of 30:2.
[4%]
C. Give 2 minutes of CPR at a compression-ventilation ratio of 30:2.
[62%]
D. Establish emergency intravenous (IV) access and prepare to administer epinephrine.
[6%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Physiological Adaptation
Related Topic
Medical Emergencies
Item Type
Item Type
Application
Explanation
Choice C is correct. Current American Heart Association (AHA) guidelines recommend that if you find an unconscious infant or child (to puberty) and are alone, you should give 2 minutes of CPR at a compression-ventilation ratio of 30:2. The nurse should shout for an AED and not leave the client. A compression-ventilation rate of 15:2 is used in 2-person CPR. For infants and children, the guidelines reaffirm the C-A-B (compressions, airway, breathing) sequence and that compressions and ventilation are needed for pediatric cardiac arrest. Compressions should be done at a rate of 100 to 120 per minute at a depth of about 1.5 inches for infants, about 2 inches for children, and at least 2 inches but no greater than 2.4 inches for adolescents.
Choices A, B, and D are incorrect. These options do not reflect best practices for basic life support. The nurse should never leave the client, and establishing IV access is not the priority over maintaining perfusion through effective CPR.
Related Videos
2 Key Topics
CPR
8.2 Risk Management & Environment Safety
Additional Info
When performing CPR, the nurse needs to minimize interruptions and focus on providing effective compressions and ventilations
➢ A compression rate of 100-120/minute is desired
➢ An AED should be made available as urgently as possible
➢ Assessing for a pulse should not take more than ten seconds
➢ When obtaining a pulse for an infant, the nurse should assess the brachial artery. For a child and adult, the nurse will use the carotid artery
➢ Immediate family members should be allowed to be present during resuscitation as this has promoted better grieving
