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 D
Explanation
If the new TPN solution is not available, the nurse should infuse dextrose 10% in water to prevent hypoglycemia.
Choice A is incorrect because disconnecting and flushing the IV access line would interrupt the client’s nutrition and could lead to hypoglycemia.
Choice B is incorrect because lactated Ringer’s solution does not provide the necessary glucose to prevent hypoglycemia.
Choice C is incorrect because decreasing the TPN infusion rate would not provide the necessary glucose to prevent hypoglycemia.
Correct Answer is B
Explanation
The nurse should consult the client before approaching the dog.
Service dogs are working animals and it is important to respect their role and the handler’s wishes.
Choice A is wrong because petting the dog briefly to demonstrate acceptance could distract the dog from its duties.
Choice C is wrong because offering the dog a bowl of water without consulting the client first could interfere with the dog’s training or schedule.
Choice D is wrong because commanding the dog to sit while talking with the client could confuse the dog and disrupt its training.
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