A nurse finds an adult client lying unconscious & unresponsive on the bathroom floor. Which action should the nurse take first?
Call for assistance.
Give 2 rescue breaths.
Check for apical pulse.
Begin chest compressions.
The Correct Answer is A
This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.
Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.
Giving rescue breaths to a client who has a pulse may cause harm.
Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.
Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.
Chest compressions may cause harm to a client who has a pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
Correct Answer is B
Explanation
Pulse oximetry works by measuring the amount of light that passes through your finger and reaches a sensor on the other side.
The amount of light that is absorbed by your blood depends on how much oxygen it carries. Nail polish can block or reflect some of the light, making it harder for the pulse oximeter to get an accurate reading of your oxygen level.
Choice A is wrong because the color of your nailbed is not relevant for pulse oximetry.
The pulse oximeter does not measure the color of your nailbed, but the amount of light that passes through it.
Choice C is wrong because the sensor does not react with the nail polish causing an allergic reaction.
The sensor is a non-invasive device that does not touch your skin or nail polish directly.
Choice D is wrong because the chemicals in the nail polish do not cause falsely decreased readings of your oxygen level.
The chemicals in the nail polish do not affect the amount of oxygen in your blood, but only the amount of light that reaches the sensor.
Normal ranges for pulse oximetry vary depending on your health condition and altitude, but generally they are between 95% and 100%. If your pulse oximetry reading is lower than 90%, you may have hypoxia, which means your tissues are not getting enough oxygen.
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