When a patient collapses due to heart failure, what is the priority assessment for the practical nurse?

When a patient collapses due to heart failure, what is the priority assessment for the practical nurse?

• A. Check for injuries caused by the fall.
• B. Take an apical pulse to assess cardiac status.
• C. Assess for breathing
• D. Observe for or establish a patent airway.

Answer: (D)

The most important thing to do first is secure an open airway. When a patient collapses, especially with heart problems, the immediate danger is not being able to breathe or oxygenate the lungs. A patent airway is the foundation for effective breathing and circulation, so the practical nurse should observe for and establish a clear airway right away, using appropriate positioning and airway maneuvers as needed. Only after the airway is open do you assess breathing and then address circulation and other concerns. Checking for injuries or taking a pulse can come after airway and breathing are being managed, but they don’t prevent hypoxia in the moment.

The most important thing to do first is secure an open airway. When a patient collapses, especially with heart problems, the immediate danger is not being able to breathe or oxygenate the lungs. A patent airway is the foundation for effective breathing and circulation, so the practical nurse should observe for and establish a clear airway right away, using appropriate positioning and airway maneuvers as needed. Only after the airway is open do you assess breathing and then address circulation and other concerns. Checking for injuries or taking a pulse can come after airway and breathing are being managed, but they don’t prevent hypoxia in the moment.