The nurse walks into the room and finds that a client who has just had surgery is diaphoretic, appears to have no respirations, and has a barely palpable pulse. The nurse should first:
1. Call a code.
2. Open the airway.
3. Start rescue breathing.
4. Start cardiac compressions.
The most appropriate immediate response is to open the airway. The nurse then should look, listen, and feel for respirations. Noting none, the nurse calls a code and attempts ventilations with a bag mask or mask with a one-way valve until the full code team responds. Using standard precautions with the mask protects the nurse from exposure to possible client microorganisms.
CN: Physiological adaptation; CL: Synthesize