A nurse finds a client in bed, unresponsive and breathing.
Which of the following actions should the nurse take first?
Initiate cardiac monitoring for the client.
Apply a blood pressure cuff.
Palpate for the client's carotid pulse.
Establish an IV access.
The Correct Answer is C
The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
“I’m too tired to brush my teeth.” This statement indicates that the client is experiencing fatigue, which is a common symptom of heart failure.
Fatigue can significantly impact a person’s ability to perform daily activities and can be an indication that the client needs a referral for cardiac rehabilitation 1.
Choice A is not the correct answer because weighing oneself daily is a recommended self-monitoring technique for clients with heart failure.
Choice B is not the correct answer because while feeling unhappy can be a symptom of heart failure, it does not necessarily indicate a need for cardiac rehabilitation.
Choice D is not the correct answer because eating a low-sodium diet is a recommended dietary change for clients with heart failure.
Correct Answer is A
Explanation
Acupuncture is commonly used to treat a wide range of illnesses and ailments including pain management, control of nausea and vomiting, fatigue, hot flashes, xerostomia, neuropathy, anxiety, depression, and sleep disturbance in cancer patients.
However, I could not find any information that suggests mouth sores (B), headaches, or urticaria (D) are contraindications for acupuncture.
Lymphedema is a contraindication for acupuncture because it can increase the risk of infection in the affected area.
It is important for the nurse to identify this as a contraindication to receiving acupuncture therapy.
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