The nurse finds a 70-year-old client admitted with heart failure, unresponsive with agonal gasping respirations. Which action does the nurse take first?

Assess the patient’s pulse. The first action upon finding an unresponsive patient is to assess for a pulse. If no pulse is found after 10 seconds, chest compressions should be started immediately while the nurse calls for help. If there is agonal breathing with a pulse, start rescue breathing. An advanced airway may be needed at some point, but not in the initial evaluation phase.

The nurse finds a 70-year-old client admitted with heart failure,...

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Physiological Adaptation
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Category: Physiological Adaptation
Difficulty: 4

Topics: Cardiovascular Delegation, Prioritization and Leadership Respiratory

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