Question

A middle-aged man collapses in the emergency department waiting room. What should the nurse do first?

1. Ask the client to state his name.
2. Perform the chin-tilt to open the victim's airway.
3. Feel for any air movement from the victim's nose or mouth.
4. Watch the victim's chest for respirations.

Answer 1

The nurse should first perform the chin-tilt to open the airway of the collapsed individual, then check for air movement and respirations. If there are no breaths, CPR should be started immediately, emphasizing chest compressions. correct answer is 2). Perform the chin-tilt to open the victim's airway.

Step-by-step explanation:

When a middle-aged man collapses in the emergency department, the nurse's first action should be to perform the chin-tilt to open the victim's airway. This initial step is crucial as it helps ensure that air can flow to the lungs if the patient is not breathing.

After the airway is opened, the nurse should quickly check for breathing by looking at the chest for respirations, feeling for air movement, and if needed, asking the patient to state his name to ascertain consciousness and ability to breathe. If there are no signs of breathing or only gasping breaths (agonal breathing), the nurse should immediately commence with cardiopulmonary resuscitation (CPR), including chest compressions and rescue breaths as current guidelines suggest.

Compressions should be deep and at a pace likened to the beat of the song 'Staying Alive'. It is vital that CPR begins as soon as possible to maintain circulation and sustain life until further medical treatment can be administered or the patient regains spontaneous breathing and heart rate.