Emergency Response Plans Practice Test 8
Emergency Response Plans NCLEX Practice Test
Emergency Response Plans is a key topic within the NCLEX test plan, located under Safe and Effective Care Environment → Safety and Infection Control → Emergency Response Plans. This section prepares nurses for disaster roles, surge protocols, and emergency communication procedures. Each test contains 50 questions designed to mirror the difficulty and variety of the real exam.
This is the 8th part of the Emergency Response Plans series. To explore all practice tests under this topic, use the “Back to Main Topic” button at the end of the page.
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Emergency Response Plans Practice Test 8
A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?
- Continue CPR without using the automated external defibrillator (AED) until paramedics arrive
- Place one AED pad on the chest and the other on the back
- Place one AED pad on the upper right chest and the other on the lower left side
- Place one AED pad on the upper right chest and dispose of the other
Explanation: Answer reason: If pediatric pads are unavailable, adult pads may be used in small children as long as the pads do not touch each other, because contact can prevent effective shock delivery and risk skin burns. An anterior-posterior (chest/back) placement increases pad separation on a small chest and is recommended when standard anterolateral placement would cause overlap. Continuing CPR without using the AED delays definitive therapy, and discarding one pad makes defibrillation impossible.
The nurse is walking through a mall parking lot and witnesses the collapse of a child. The child is not breathing and has a pulse of 50/min. After the nurse calls emergency services and delivers rescue breaths for 2 minutes, the child is still not breathing and is now pale with a pulse of 49/min. What is the nurse's next action?
- Assess the child's airway
- Begin chest compressions
- Continue rescue breathing
- Perform abdominal thrusts
Explanation: Answer reason: After 2 minutes of effective ventilation, the child remains apneic and is now pale with a pulse of 49/min, indicating inadequate circulation despite oxygenation attempts. The appropriate next step is to start chest compressions while continuing ventilations (CPR). Continuing rescue breathing alone is no longer sufficient because the heart rate is below the CPR threshold with clinical signs of poor perfusion.
A client is having a seizure when the nurse enters the room. What should be the most appropriate action of the nurse?
- Note the first area that starts to seize.
- Take note of the time the seizure began and how long it lasted.
- Place pads on the side rails.
- Provide privacy to the client during the seizure.
Explanation: Answer reason: The immediate nursing priority during an active seizure is safety assessment and rapid identification of prolonged seizure activity that may require emergent treatment. Timing the onset and duration is essential to recognize status epilepticus risk and to guide medication decisions and provider notification. Protective measures like padding side rails are important but should ideally be in place beforehand and must not delay monitoring of duration and airway/safety. Documenting the seizure’s progression is useful, but duration is the most critical real-time datum for urgent clinical decisions.
A client admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action should the nurse take next?
- Defibrillate at 200 J.
- Establish IV access.
- Place an oral airway and ventilate.
- Start cardiopulmonary resuscitation (CPR).
Explanation: Answer reason: Ventricular fibrillation is a pulseless, shockable cardiac arrest rhythm, and immediate high-quality chest compressions are the first action after confirming unresponsiveness to maintain coronary and cerebral perfusion. CPR is initiated while the defibrillator is being brought in/charged because any delay in compressions reduces the likelihood of successful defibrillation and ROSC. Defibrillation is the definitive therapy for VF, but it is performed as soon as the defibrillator is ready, not before starting compressions. Establishing IV access or placing an airway are secondary priorities and should not interrupt early compressions and rapid defibrillation in pulseless VF.
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take?
- Perform synchronized cardioversion.
- Start cardiopulmonary resuscitation (CPR).
- Administer atropine per agency dysrhythmia protocol.
- Provide supplemental oxygen via non-rebreather mask.
Explanation: Answer reason: In an apneic, pulseless patient, the priority is immediate initiation of the cardiac arrest algorithm to restore circulation and oxygen delivery. A monitor rhythm that appears like sinus tachycardia can still represent pulseless electrical activity, which is treated with high-quality chest compressions and rapid activation of the resuscitation response. Synchronized cardioversion is reserved for unstable tachyarrhythmias with a pulse, not for pulseless arrest. Atropine is for symptomatic bradycardia, and applying a non-rebreather delays definitive life-saving circulation support when there is no pulse.
Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position. The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take?
- Administer epinephrine
- Begin positive pressure ventilation
- Continue stimulating the newborn
- Start chest compressions
Explanation: Answer reason: A heart rate <100/min with gasping or apnea after initial steps requires immediate positive-pressure ventilation to establish effective oxygenation and improve heart rate. Chest compressions are reserved for persistent heart rate <60/min after at least 30 seconds of effective ventilation, so starting compressions now is premature. Epinephrine is indicated only if the heart rate remains <60/min despite effective ventilation and compressions.
A patient presents with signs of anaphylaxis after a bee sting. Which medication should the nurse administer first?
- Antihistamine.
- Epinephrine.
- Corticosteroid.
- Bronchodilator.
Explanation: Answer reason: Anaphylaxis is a life-threatening airway and circulatory emergency requiring immediate reversal of bronchospasm, mucosal edema, and vasodilation. This drug rapidly provides alpha-1 vasoconstriction to raise blood pressure and reduce airway swelling and beta-2 bronchodilation to improve ventilation. Antihistamines and corticosteroids are adjuncts with slower onset and do not promptly correct shock or airway compromise. Bronchodilators can help wheezing but do not treat the underlying vasodilation and edema driving anaphylactic collapse.
A 21-year-old woman in active labor is admitted to the labor suite. An hour later, the membranes rupture spontaneously. The nurse observes a glistening white cord protruding from the vagina. Which of the following actions should the nurse take FIRST?
- Return to the nurses’ station and place an emergency call to the physician.
- Administer oxygen by mask at 10–12 L/min and assess the mother’s vital signs.
- Place a clean towel over the cord and wet it with sterile normal saline.
- Apply manual pressure to the presenting part and have the mother assume a knee-chest position.
Explanation: Answer reason: Umbilical cord prolapse is an obstetric emergency because cord compression rapidly compromises fetal oxygenation. The immediate priority is to relieve pressure off the cord by elevating the presenting part and using a gravity-assisted position (knee-chest) to reduce compression while preparing for urgent delivery. Calling the provider and administering oxygen are important but do not address the immediate cause of fetal hypoxia if the cord remains compressed. Covering the cord with moist sterile gauze helps prevent vasospasm and drying, but it is secondary to immediately relieving compression.
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention?
- Stay with the patient and monitor their vital signs while another nurse notifies the physician.
- Place a sterile dressing over the site and tape it on three sides and notify the physician.
- Attempt to re-insert the tube.
- Keep the site open to air and notify the physician.
Explanation: Answer reason: A dislodged chest tube creates an open pneumothorax risk, so the priority is to prevent additional air entry into the pleural space while allowing air to escape. A sterile occlusive dressing taped on three sides functions as a flutter valve to minimize inspiratory air ingress and reduce progression to tension physiology. Reinsertion is outside nursing scope and can cause tissue injury and contamination. Simply monitoring or leaving the site open fails to address the immediate life-threatening air leak.
The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks’ gestation with Apgar scores of 1 and 4. When planning for the admission of this infant which is the nurse’s highest priority?
- Turning on the apnea and cardiorespiratory monitor
- Connecting the resuscitation bag to the oxygen outlet
- Setting up the intravenous line with 5% dextrose in water
- Setting the radiant warmer control temperature at 36.5°C (97.6°F)
Explanation: Answer reason: Preparing functional positive-pressure ventilation equipment is the most time-critical intervention because ventilation is the primary corrective step in neonatal resuscitation and rapidly improves heart rate. Monitoring and warming are important supportive measures, but they do not correct apnea or poor ventilation. Starting an IV with D5W is not the first priority in initial stabilization and may delay life-saving ventilation readiness.
You are working in the emergency department and find out that a tornado has hit the local area. Numerous casualties are being sent to the emergency department. What action should you take at this time?
- Prepare the triage room.
- Obtain additional supplies.
- Activate the agency disaster plan.
- Call in additional staff.
Explanation: Answer reason: Mass-casualty incidents require a coordinated, predefined command structure to rapidly allocate resources, establish triage flow, and maintain safety. Initiating the facility’s disaster plan triggers the incident command system, clarifies roles, opens surge capacity processes, and mobilizes communications and supply chains in the correct sequence. Actions like preparing triage space, getting supplies, or calling staff are important but should be done under the standardized protocol to prevent duplication, missed steps, and unsafe improvisation. The disaster plan also ensures documentation, security, and patient tracking processes are implemented early when volume will quickly overwhelm normal operations.
The medical center encounters a bomb threat. The emergency response team informs the staff that the threat is legitimate and that clients should start being evacuated. Which of the following clients should the nurse begin evacuating FIRST to the safe designated area?
- Ambulatory clients
- Bedridden clients
- ICU clients
- Infant clients
Explanation: Answer reason: Clients who can walk require minimal assistance and can be directed to the designated safe area immediately, quickly reducing the number of individuals at risk. This also frees staff to return promptly to assist clients who need substantial support (e.g., bedridden or ICU clients). Evacuating high-acuity or immobile clients first can bottleneck the process and delay overall movement to safety.
The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first?
- Defibrillate the client at 200 J.
- Check the client for a pulse.
- Cardiovert the client at 50 J.
- Give the client IV lidocaine.
Explanation: Answer reason: The immediate priority with a monitor rhythm of ventricular tachycardia is to determine whether it is pulseless or perfusing, because management differs drastically. A rapid pulse check confirms whether to proceed with defibrillation/CPR (pulseless VT) versus synchronized cardioversion or antiarrhythmic therapy (VT with a pulse). Acting on the monitor alone risks delivering an inappropriate shock or delaying life-saving CPR. Establishing the patient’s hemodynamic status first is the safest first action.
A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first?
- Perform immediate defibrillation.
- Give epinephrine (Adrenalin) IV.
- Prepare for endotracheal intubation.
- Give ventilations with a bag-valve-mask device.
Explanation: Answer reason: The described rhythm (chaotic, varying undulations without identifiable complexes) in an unconscious, pulseless patient is ventricular fibrillation, which is a shockable cardiac arrest. The priority intervention is rapid defibrillation to terminate disorganized ventricular activity and allow a perfusing rhythm to return. Epinephrine is given during CPR after initial defibrillation attempts and does not replace early shock for VF/pulseless VT. Airway interventions (BVM or intubation prep) are supportive but should not delay immediate defibrillation in a witnessed/monitored shockable arrest.
The client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?
- Apply an eye patch.
- Perform visual acuity tests.
- Irrigate the eye with sterile saline.
- Remove the piece of wood using a sterile eye clamp.
Explanation: Answer reason: With a penetrating eye injury and an impaled object, the priority is to prevent further ocular damage by avoiding any pressure or manipulation that could worsen the globe injury. Shielding/protecting the eye is the safest immediate nursing action to stabilize the injury until definitive ophthalmologic management. Irrigation or attempting to remove the object can convert a controlled injury into a catastrophic rupture and increase bleeding or extrusion of intraocular contents. Visual acuity assessment is important, but protection/stabilization takes precedence when an object is visibly protruding and the risk of worsening injury is high.
An 82-year-old man presents to the emergency department after a ground-level fall. The paramedics tell you that the left pupil was fixed and dilated. Upon arrival, the patient's elbows, wrists, and fingers are flexed, and legs extended and rotated inward. What is the most important intervention for this patient?
- Obtain IV access immediately
- Turn patient on his side
- Obtain accurate history from the family
- Take him straight to the CT scan
Explanation: Answer reason: The priority is immediate stabilization of life-threatening neurologic injury using an ABC approach while preparing for definitive management. A fixed, dilated pupil with posturing suggests severe intracranial pathology with impending herniation, and the patient may rapidly decompensate requiring rapid sequence intubation, hyperosmolar therapy, sedation, and vasopressors. Establishing IV access is the fastest enabling intervention to deliver time-critical resuscitative medications and fluids while other actions (airway management, neurosurgical consult, imaging) are being coordinated. Going straight to CT delays stabilization and risks cardiorespiratory collapse en route, and obtaining history is not time-critical in the setting of signs of herniation. Turning the patient on his side may be useful for vomiting/aspiration risk but does not address the immediate need to support resuscitation and prevent secondary brain injury.
A nurse assesses an infant with a heart rate of 50, cyanotic, and apneic. The nurse should initially?
- Start chest compressions.
- Notify the code/rapid response team.
- Deliver rescue breaths.
- Obtain intravenous access.
Explanation: Answer reason: In infants, a heart rate <60/min with signs of poor perfusion despite oxygenation/ventilation indicates the need to begin CPR with compressions because cardiac output is critically inadequate. This infant is apneic and cyanotic with bradycardia (50), which is consistent with impending cardiopulmonary arrest, so compressions should start immediately while ventilation is provided as part of coordinated CPR. Activating the emergency team is important but must not delay immediate life-saving actions at the bedside. Establishing IV access is a later step once effective CPR is underway and additional help/equipment arrives.
After change-of-shift report, which newly admitted patient should the nurse assess first?
- A patient with human immunodeficiency virus (HIV) whose CD4 count is 45 mm3 (45 cells/mcL)
- A patient with acute kidney transplant rejection who has a scheduled dose of prednisone due
- A patient with graft-versus-host disease who has frequent liquid stools
- A patient with hypertension who has angioedema after receiving lisinopril
Explanation: Answer reason: This presentation requires immediate assessment of airway patency, breathing, oxygenation, and readiness for urgent interventions (e.g., stopping the drug, notifying the provider/rapid response, preparing for epinephrine and advanced airway support as ordered). The other patients are high risk but not as immediately life-threatening in the next minutes: severe immunosuppression (CD4 45) needs protective precautions and infection assessment, GVHD diarrhea needs fluid/electrolyte evaluation, and transplant rejection with prednisone due is important but not more urgent than potential airway compromise. Prioritization follows ABCs, making possible airway obstruction the first assessment.
The nurse administers medications to the client diagnosed with bipolar disorder. The client approaches the nurse and begins to throw things. Which action does the nurse take?
- Sits down and asks the client what is bothering the client.
- Gives the client the medications so the client will calm down.
- Admonishes the client and suggests that the client collect self.
- Gets another nurse to assist with the client.
Explanation: Answer reason: Immediate priority in an escalating behavioral emergency is safety for the client, staff, and other patients using the least restrictive, team-based approach. Calling for assistance provides adequate staffing to maintain control of the environment, implement de-escalation and limit-setting, and be prepared for emergency interventions if needed. Trying to sit and explore feelings during active throwing delays containment and increases risk of injury. Offering medications “to calm down” is not appropriate as a first response in an acute unsafe situation and may be refused, while scolding tends to escalate agitation.
The nurse and group of friends are at the lake. Suddenly, someone says, “Look across the lake! It looks like someone might be drowning out there!” What is the nurse’s first action?
- Determine who is the strongest swimmer in the group.
- Direct someone to locate a cell phone and call 911.
- Find a boat, raft, or some type of flotation device.
- Use a pair of binoculars and look across the lake.
Explanation: Answer reason: In a suspected drowning, the priority is rapid activation of the emergency response system so trained rescuers and advanced life support can be dispatched while bystanders initiate safe rescue measures. Delegating a specific person to call 911 immediately reduces delay and allows the nurse to coordinate scene safety and next steps. Entering the water or organizing a swim rescue is high-risk and should not occur before help is activated and safer “reach/throw/row” options are considered. Searching for a flotation device is important, but it should follow immediate EMS activation rather than replacing it as the first action.
A nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
- Initiate CPR
- Assess the pulse
- Perform defibrillation
- Assess the level of consciousness
Explanation: Answer reason: The immediate priority is to determine whether the patient is pulseless, which distinguishes cardiac arrest (requiring CPR and rapid defibrillation for VF/pulseless VT) from a perfusing rhythm scenario needing different actions. A quick pulse check (along with rapid responsiveness check) confirms the need to activate the arrest response and proceed with compressions/defibrillation. Initiating CPR or defibrillation without confirming pulselessness risks inappropriate treatment if the monitor finding is not matched by the clinical assessment.
While volunteering at a summer camp as the RN on duty, a child playing soccer falls and breaks their arm. It appears to be a compound fracture. Place the following actions in order of nursing priority when dealing with this injury?
- Assess the injury while calling for help
- Apply ice to the area
- Elevate the arm
- Cover the open wound with a clean dressing
Explanation: Answer reason: Early assessment identifies immediate threats such as uncontrolled hemorrhage or compromised circulation that can lead to limb ischemia and shock. After help is mobilized, covering the open wound reduces contamination risk while awaiting immobilization and transport. Ice and elevation are supportive measures to limit swelling and pain but come after life/limb-threatening concerns are addressed.
The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care?
- 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia and stiff neck
- 36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C) and foul-smelling drainage from self-injection sites
- 45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F (38.3 C) and a serum glucose of 295 mg/dl (16.4 mmol/L)
- 76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive cough of thick green mucus
Explanation: Answer reason: 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia and stiff neck This presentation suggests acute bacterial meningitis with a high risk for rapid deterioration, sepsis, increased intracranial pressure, and airway/hemodynamic compromise. It also demands immediate droplet precautions and urgent diagnostic/therapeutic actions (cultures and prompt antibiotics) to reduce mortality and transmission. Compared with localized skin/soft tissue infection, chronic osteomyelitis with hyperglycemia, or bronchitis with purulent sputum, meningococcal disease is more time-critical and life-threatening. Prioritizing this client aligns with addressing the most unstable, high-acuity condition and preventing spread to others.
You are the permanently assigned nurse in an adult medical-surgical floor. You hear a “Code Pink” over the public address system. You know that a “Code Pink” means an infant abduction, and you have a small role in infant abductions, but you also know that your hospital has fire drills and infant abduction drills every 2 months. Because you are working in the adult medical-surgical area without infants, you?
- Must respond and perform your role in this code.
- Ask the unit secretary to go to the code for you.
- Ignore the code because you are caring for clients.
- Ignore the code because you are not in the nursery.
Explanation: Answer reason: Facility emergency codes require all staff to implement their assigned responsibilities to protect patients and support a coordinated response. An infant abduction alert is a security emergency where roles often include monitoring exits, challenging suspicious persons per policy, and maintaining unit control, even on adult units. Delegating to the unit secretary is inappropriate because the nurse retains accountability and the secretary’s role/training may differ from the code plan. Ignoring the overhead page because of current assignments or unit location delays containment and increases risk, which conflicts with mandated emergency procedures.
A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position?
- Prone
- Supine
- On the side
- Reverse Trendelenburg's
Explanation: Answer reason: The immediate nursing priority is to relieve cord pressure by using a position that elevates the pelvis and shifts the fetus off the cord with gravity. Knee-chest positioning (client prone with hips elevated) is a standard first action while preparing for urgent delivery and maintaining fetal perfusion. Supine positioning worsens aortocaval and cord compression risk, and reverse Trendelenburg lowers the pelvis, increasing pressure on the cord.
A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the priority nursing action?
- Assess vital signs
- Contact family members
- Encourage the client to recall recent events
- Perform a mental status assessment
Explanation: Answer reason: A client found after 48 hours missing is at high risk for dehydration, hypothermia/heat exposure, intoxication, infection, trauma, or metabolic derangements that can cause acute confusion and amnesia. Checking vital signs is the fastest way to identify immediate instability requiring urgent intervention and guides further assessment (e.g., glucose, oxygenation, temperature management). A focused mental status assessment is important, but it comes after ensuring the client is hemodynamically and respiratorily stable and not experiencing an occult medical emergency.
The home health nurse is assessing a client in their home with suspected carbon monoxide poisoning. The nurse should take which priority action?
- Move the client outdoors
- Notify the primary healthcare provider (PHCP)
- Auscultate the client's lung sounds
- Assess the client's pulse oximetry
Explanation: Answer reason: Carbon monoxide poisoning is a time-critical environmental emergency where the immediate priority is to stop ongoing exposure and restore oxygen delivery. Removing the client to fresh air rapidly reduces further inhalation and is the first step before additional assessment or notifications. Pulse oximetry can appear falsely normal in carbon monoxide poisoning because it cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin, so it must not delay removal from the source. After evacuation, the nurse can activate emergency response/EMS and arrange high-flow oxygen and further evaluation, including carboxyhemoglobin measurement.
The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then?
- Activate the fire alarm.
- Extinguish the fire.
- Contact the nursing supervisor.
- Close the door to the client's room.
Explanation: Answer reason: Fire response follows RACE: Rescue, Alarm, Contain, Extinguish/Evacuate. After the client has been rescued, activating the alarm is the next priority to initiate the facility’s emergency response, alert staff, and summon the fire department. Closing the door is an important containment step but comes after ensuring the alarm has been triggered. Attempting to extinguish the fire is only appropriate after the alarm is activated and the fire is small/contained with an appropriate extinguisher and safe exit available.
A client has been defibrillated three times. The nurse observes that the attempts to convert the ventricular fibrillation were unsuccessful. Based on an evaluation of the situation, the nurse anticipates that which of the following actions would be best?
- Performing cardiopulmonary resuscitation (CPR)
- Terminating the resuscitation effort
- Administering sodium bicarbonate intravenously
- Defibrillating three more times at 400 joules
Explanation: Answer reason: After an unsuccessful shock sequence, resuscitation algorithms direct rescuers to resume chest compressions promptly rather than pausing for repeated shocks. Routine sodium bicarbonate is not indicated in VF/pulseless arrest unless specific causes exist (e.g., hyperkalemia, tricyclic overdose, prolonged arrest with severe acidosis). Terminating efforts is inappropriate without meeting clear cessation criteria, and repeatedly escalating shocks without CPR increases no-flow time and worsens outcomes.
A client who was recently discharged from the psychiatric unit telephones the unit to speak to the nurse. The client states that she took her children to the neighbors’ house and has turned on the gas to kill herself. She is home alone and gives the nurse her address. Which of the following actions should the nurse do next?
- Refer the caller to a 24-hour suicide hotline.
- Tell the caller that another nurse will telephone the police.
- Ask the caller whether she telephoned her physician.
- Instruct the caller to telephone her family for help.
Explanation: Answer reason: Imminent suicide with an active method in progress (gas exposure) is a time-critical emergency requiring immediate activation of emergency services for a welfare check and rapid intervention. The nurse should keep the caller engaged on the phone while ensuring 911/police are contacted without delay, using available staff to place the call. Referral to a hotline or advising the client to call family/physician introduces unsafe delay and relies on the suicidal person to take protective action. Immediate emergency response best addresses the acute lethal risk and prioritizes client safety over routine follow-up steps.
A nurse assesses an infant with a heart rate of 50, cyanotic, and apneic. The nurse should initially?
- Start chest compressions.
- Notify the code/rapid response team.
- Deliver rescue breaths.
- Obtain intravenous access.
Explanation: Answer reason: In infants, most cardiac arrests are secondary to respiratory failure, so establishing effective ventilation is the priority when the child is apneic and cyanotic. Providing positive-pressure ventilation with high-quality rescue breaths can correct hypoxemia and may improve bradycardia rapidly. Chest compressions are started when the heart rate remains <60/min despite adequate ventilation and oxygenation rather than as the first step here. Activating the code team and obtaining IV access are important but should not delay immediate airway and breathing support.
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