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
Explanation
This is the most appropriate action because it respects the client’s right to know and the family’s right to privacy.
It also allows the nurse to collaborate with the family and the healthcare provider to provide the best care for the client.
Choice B is wrong because it violates the client’s autonomy and dignity.
It also prevents the client from making informed decisions about end-of-life care.
Choice C is wrong because it denies the reality of the situation and does not address the client’s concerns.
It also may increase the client’s anxiety and frustration.
Choice D is wrong because it disregards the family’s wishes and cultural values.
It also may cause harm to the client and the family by breaking their trust and creating conflict.
Correct Answer is A
Explanation
The client should not eat anything before the barium enema, as this could interfere with the visualization of the colon. The client should also take a laxative and an enema the night before the test to clear the bowel of any fecal matter.
Choice B is wrong because the client may need to have laxatives to expel the barium after the test, not before. Barium can cause constipation and impaction if not eliminated promptly.
Choice C is wrong because the client will receive the barium prior to the study by rectum, which is correct. The barium is a contrast agent that helps outline the colon on X-rays.
Choice D is wrong because the client will need to lie down during the study while retaining the barium for X-rays, which is correct. The client may also be asked to change positions to allow different views of the colon.
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