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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

You need to speak to the designated hospital contact. This is because the nurse has a duty to protect the client’s privacy and confidentiality, and cannot disclose any information about the client’s diagnosis or condition to the reporter without the client’s consent.

The nurse should refer the reporter to the hospital’s public relations department or spokesperson, who is authorized to handle such inquiries.

Choice A is wrong because it implies that the client’s healthcare provider can release the information without the client’s consent, which is not true.

Choice B is wrong because it confirms that the client is on the unit, which is a violation of the client’s privacy.

Choice C is wrong because it gives false information about the client’s status, which is unethical and unprofessional.

A. The nurse establishes rapport with the client in an inpatient psychiatric setting. B. The nurse documents accurately and honestly in the electronic health record. C. The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. D. The nurse refers to the policy of the inpatient psychiatric setting when uncertain of a standard of care.

Correct Answer is C

Explanation

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse finds an adult client lying unconscious & unresponsive on the bathroom floor. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A television reporter calls the nursing unit requesting an update on the status of an elected official from the community who was admitted to the unit. Which statement is the most appropriate response by the nurse when the reporter requests the official diagnosis?

Correct Answer is D

Explanation

A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Correct Answer is C

Explanation

A client with terminal cancer is admitted to hospice care. The daughter is documented as the client’s health care proxy agent. Which statement made by the nurse demonstrates an understanding of health care proxy and care?

A client has been taking aspirin 325 mg six to eight times a day for the past two weeks to control pain from a knee injury. Which symptom reported by the client should the nurse report to the health care provider (HCP) for priority follow-up?

The nurse has developed a pain management plan for a client who has a history of opioid drug abuse. Which of the following statements by the client demonstrates understanding of the pain management plan?

A nurse is teaching a client about preparation for a barium enema. What client statement indicates the client requires further reinforcement of teaching?

Warfarin sodium (Coumadin) is ordered for a client. The client asks the nurse about dietary restrictions while taking this medication. Which of the following foods should be limited?

Which client has the greatest need for special mouth care?

Which assessment finding should a nurse record as a symptom of pain? A client who:.

A client with dysphagia is eating breakfast and suddenly slumps over. What should the nurse do first?