A client admitted with angina complains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which of the following actions should the nurse take first?
A. Activate the resuscitation team.
B. Open the client’s airway.
C. Check for breathing.
D. Check for signs of circulation.
Correct Answer: A. Activate the resuscitation team.
Immediately after establishing unresponsiveness, the nurse should activate the resuscitation team. The next step is to open the airway using the head-tilt, chin-lift maneuver and check for breathing (looking, listening, and feeling for no more than 10-seconds). If the client isn’t breathing, give two slow breaths using a bag mask or pocket mask. Next, check for signs of circulation by palpating the carotid pulse.
Option B: The initial step in the evaluation of an unconscious patient is to evaluate for the basic signs of life. The American Heart Association recommends examining for a pulse, followed by assessing for airway patency and breathing pattern. If the patient does not have a pulse or does not have a regular breathing pattern, basic life support/advanced cardiovascular life support is indicated.
Option C: For patients with a pulse, who are breathing adequately, the evaluation shifts to a detailed neurological examination. The neurologic examination would serve to determine the location and nature of the neurological lesion and to determine prognosis.
Option D: The initial step is to evaluate for reactivity, using objective measures. Address the patient verbally, and then progress to light shaking, then progress to more intense mechanical stimulation. Sufficient stimulus to the supraorbital ridge, nail beds, or temporomandibular joint can be painful without risk of tissue injury.
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