RN Nursing · Acute Myocardial Infarction · Practice question
A nurse is caring for a client who has a full code status. The client has experienced cardiac arrest and has activity on the electroencephalogram. Which of the following nursing interventions should the nurse perform?
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Perform a head-to-toe assessment.
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Begin chest compressions but hold rescue breathing.
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✓
The nurse should begin full cardiopulmonary resuscitation (CPR) immediately.
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Hold cardiopulmonary resuscitation (CPR) until orders are confirmed.
Answer & explanation
Correct: The nurse should begin full cardiopulmonary resuscitation (CPR) immediately.
When a client with full code status experiences cardiac arrest, the nurse must begin full cardiopulmonary resuscitation immediately. A full code designation means the client or their surrogate has consented to all resuscitative measures, including chest compressions and rescue breathing. The presence of electroencephalogram activity indicates some degree of neurological function, which reinforces the need to act quickly to restore circulation and protect brain tissue. Delaying CPR to confirm orders is inappropriate and dangerous — every second without perfusion increases the risk of irreversible brain injury and death; a full code order is already in place and does not require further confirmation before acting. Performing a head-to-toe assessment before initiating resuscitation would waste critical time and is contraindicated during cardiac arrest. Beginning chest compressions while withholding rescue breathing would be appropriate only if the nurse were an untrained bystander following hands-only CPR guidelines, which does not apply to a nurse acting within a clinical environment with a full code order. Standard CPR protocol requires both compressions and ventilations at a ratio of 30:2 for adults until an advanced airway is secured. Therefore, initiating full CPR immediately is the correct and legally appropriate action.
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