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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

This statement indicates that the nurse understands the importance of limiting the exposure of family members to radiation from the sealed implant.
Choice B is incorrect because the dosimeter badge should not be given to the oncoming nurse at the end of the shift.
The dosimeter badge is used to measure an individual’s exposure to radiation and should be worn by the same person throughout their shift.
Choice C is incorrect because if the client’s implant dislodges, the nurse should not touch it with their hands, even if they are wearing gloves.
The nurse should follow the facility’s protocol for handling dislodged implants.
Choice D is incorrect because soiled linens from a client with a sealed radiation implant do not need to be removed from the room after each change.
The linens can be handled according to standard precautions.

A. Remove the indwelling urinary catheter. B. Decrease traction on the catheter. C. Administer ibuprofen 400 mg for pain relief. D. Flush the catheter manually with 0.9% sodium chloride.

Correct Answer is D

Explanation

“Flush the catheter manually with 0.9% sodium chloride.” The client is receiving continuous bladder irrigation following a transurethral resection of the prostate and reports bladder spasms and decreased urinary output.
These symptoms may indicate that the catheter is blocked with blood clots.
Flushing the catheter manually with 0.9% sodium chloride can help to remove any blood clots and restore urinary output.
Choice A is not the correct answer because removing the indwelling urinary catheter would not address the underlying issue of blood clots blocking the catheter.
Choice B is not the correct answer because decreasing traction on the catheter would not address the underlying issue of blood clots blocking the catheter.
Choice C is not the correct answer because while ibuprofen may provide some pain relief, it would not address the underlying issue of blood clots blocking the catheter.

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A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms and the nurse observes decreased urinary output. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse finds a client in bed, unresponsive and breathing.

Which of the following actions should the nurse take first?