A client collapses while ambulating in the hallway. The nurse calls for help after verifying that the client is not breathing and has no palpable pulse. Which intervention should the nurse implement?
Explanation & Rationale
A. Begin chest compressions at a depth of at least 2 in (5.1 cm): Initiating high-quality chest compressions immediately is the priority in a pulseless and non-breathing client. This promotes circulation of oxygenated blood to vital organs, and improves chances of survival until defibrillation or advanced care is available. B. Perform forceful sternal rub to check for unresponsiveness: A sternal rub is used to assess responsiveness, but it is unnecessary once the client is confirmed to be unresponsive, pulseless, and not breathing. Delaying compressions could reduce survival chances. C. Assess the client for any obvious injuries due to the sudden fall: While it is important to note injuries, it is not the immediate priority in a client without a pulse or respirations. Life-saving measures such as CPR should take precedence over secondary assessments. D. Remove the client's clothes and apply automated external defibrillator (AED) pads to chest: Applying the AED is a critical step but should follow the immediate initiation of chest compressions. If another responder is present, tasks can be divided, but CPR should not be delayed for AED pad placement.