The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

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11ecbb05_c969_6256_b433_b99be3a336c3_MD0009_00 The basic life support sequence is compressions, airway, and breathing (mnemonic - CAB). High-quality CPR is associated with improved client outcomes and begins with high-quality chest compressions (ie, 100-120/min, 2-2.4 in [5-6 cm] deep). Any unwitnessed collapse should be treated with 2 minutes of CPR, followed by activating the emergency response system and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume high-quality chest compressions immediately (Option C). (Option A) Chest compressions should not be interrupted for more than 10 seconds when assessing for a pulse and chest rise/fall. (Option B) Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to clients who have a pulse but are not breathing normally. For clients with no pulse, the nurse should deliver cycles of 30 compressions followed by 2 rescue breaths. (Option D) The jaw-thrust maneuver is used instead of the head-tilt/chin-lift method in clients who may have a head/spinal injury. Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing. Assessing the airway is not indicated at this time. Educational objective: In basic life support for an unresponsive, pulseless client, the nurse should begin with 2 minutes of CPR in cycles of 30 high-quality chest compressions to 2 rescue breaths, followed by activating the emergency response system and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume chest compressions immediately.

The Nurse on a Medical Surgical Unit Enters a Room