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 A
Explanation
Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus and is most likely to be contracted from contaminated food or water or from close contact with a person or object that’s infected.
The hepatitis A vaccine can protect against hepatitis A and is recommended for travelers to high-risk areas.
Choice B is incorrect because hepatitis A is not transmitted through blood-to-blood exposure but rather through ingestion of contaminated food or water or through direct contact with an infectious person.
Choice C is incorrect because antibiotics are not used to treat viral infections such as hepatitis
A. Choice D is incorrect because the incubation period of hepatitis A is typically 2-6 weeks, not 5-10 days.
Correct Answer is {"xRanges":[101.765625,141.765625],"yRanges":[263.609375,303.609375]}
Explanation
A pericardial friction rub is highly specific for acute pericarditis and is generally heard over the left sternal border.
It is often louder at inspiration but sometimes can be better heard on forced expiration while the patient bends forward.
Choice A is not the answer because it does not correspond to the left sternal border.
Choice B is not the answer because it does not correspond to the left sternal border.
Choice D is not the answer because it does not correspond to the left sternal border.
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