10. An RN makes a home visit to a client who is 62 years old, and finds that the client is not responding to verbal stimuli and has no pulse or respirations, and the skin is cool to touch. The nurse's first action should be to:
10. An RN makes a home visit to a client who is 62 years old, and finds that the client is not responding to verbal stimuli and has no pulse or respirations, and the skin is cool to touch. The nurse's first action should be to:
. Do mouth-to-mouth resuscitation, 2 breaths.
. Do chest compression.
. Call emergency response (911).
. Call the family first.
Test-Taking Tip
All answers are actions that need to be taken. Know the steps to take when a client is discovered who is unresponsive.
Content Area: Geriatrics, Cardiopulmonary; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because activating the emergency medical services (EMS) is first, followed by the CAB sequence (compression, airway, breathing) of cardiopulmonary resuscitation (CPR). Answer 2 is incorrect because activating the EMS is first, then the CAB sequence of CPR. Answer 3 is correct because the emergency response system needs to be activated before beginning CPR so that support services can arrive as quickly as possible. Answer 4 is incorrect because resuscitation of the client is a priority. Calling the family would delay starting CPR.