The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and there are no other caregivers present. Which action should the nurse take first?

Question

Quizplus · Accepted Answer

Cardiac arrest is the sudden cessation of cardiac output that is usually caused by an arrhythmia. Arrest can be precipitated by a variety of factors (eg, hypoxia, toxins, electrolyte imbalance) and is a medical emergency. In children, cardiac arrest is commonly caused by hypoxia and respiratory failure. If the nurse is a single rescuer in a witnessed cardiac arrest of a pediatric client, the first action is to promptly initiate CPR, starting with chest compressions (Option A). For the pediatric client, initiating CPR before other interventions (eg, calling 911) helps minimize risk for end organ damage and brain injury. The nurse should provide 30 chest compressions and 2 rescue breaths in each cycle of CPR. (Option B) For a client with a tracheostomy tube and mechanical ventilator, the nurse should disconnect the client from the ventilator and give rescue breaths using a bag valve device. However, the nurse should first initiate chest compressions. (Options C and D) If the nurse is still alone after 2 minutes (~5 cycles) of CPR, it is appropriate to pause CPR to activate the emergency response system and obtain the automated external defibrillator, if available. Educational objective: Cardiac arrest, the sudden cessation of cardiac output, is a medical emergency. If a single rescuer witnesses cardiac arrest in a pediatric client, the rescuer should immediately begin CPR (starting with chest compressions) for 2 minutes (~5 cycles) before activating the emergency response system and obtaining an automated external defibrillator.

The Home Health Nurse Is Providing Care for a 6-Year-Old