A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?

Starting chest compressions

Obtaining a central line

Completing a comprehensive assessment

Providing rescue breathing

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting chest compressions is the priority intervention for a client who is unresponsive, not breathing, and without a pulse. This situation indicates cardiac arrest, and immediate chest compressions are crucial to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions improves the chances of survival and neurological outcomes.

Choice B reason: Obtaining a central line is not an immediate priority in the context of cardiac arrest. While central lines are important for administering medications and fluids, the first step in resuscitation is to establish effective chest compressions. Central line placement can be considered after initial resuscitation efforts are underway.

Choice C reason: Completing a comprehensive assessment is important, but it is not the immediate priority in a cardiac arrest situation. The primary focus should be on initiating chest compressions and basic life support measures. A detailed assessment can be performed once the client is stabilized.

Choice D reason: Providing rescue breathing is part of cardiopulmonary resuscitation (CPR), but it should follow the initiation of chest compressions. Current guidelines emphasize the importance of starting chest compressions immediately and then integrating rescue breaths. Effective chest compressions are the foundation of CPR.

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Correct Answer is C

Explanation

Choice A Reason:

A pureed diet consists of foods that are blended to a smooth consistency. This type of diet is typically recommended for clients who have severe swallowing difficulties or are at risk of aspiration. While it can be easier to consume for those with significant dental issues, it may not provide the variety and texture that a mechanical soft diet offers, which can be more satisfying and nutritionally adequate for someone with multiple cavities and missing teeth.

Choice B Reason:

A soft diet includes foods that are easy to chew and swallow but are not necessarily blended or pureed. This diet is often recommended for clients recovering from surgery or those with mild chewing difficulties. However, for a client with multiple cavities, chipped, and missing teeth, a soft diet might still pose challenges in terms of chewing and could lead to discomfort or inadequate nutrition.

Choice C Reason:

A mechanical soft diet is specifically designed for individuals who have difficulty chewing but do not require pureed foods. This diet includes foods that are easy to chew and swallow, such as ground meats, cooked vegetables, and soft fruits. It provides a balance of texture and nutrition, making it the most appropriate choice for a client with multiple cavities, chipped, and missing teeth. This diet helps ensure the client can eat comfortably and maintain adequate nutrition.

A. N95 (personal respirator mask). B. Surgical mask. C. They don’t need a mask. D. Only the client needs a mask.

Correct Answer is A

Explanation

Choice A Reason:

“N95 (personal respirator mask)” is correct because varicella (chickenpox) is an airborne disease. The N95 mask is designed to filter out at least 95% of airborne particles, making it essential for protecting healthcare workers from inhaling infectious agents.

Choice B Reason:

“Surgical mask” is incorrect because while surgical masks provide a barrier against large respiratory droplets, they do not offer sufficient protection against airborne particles. Varicella can be transmitted through tiny airborne droplets, which necessitates the use of an N95 mask.

Choice C Reason:

“They don’t need a mask” is incorrect because healthcare workers must wear appropriate personal protective equipment (PPE) to prevent the spread of infectious diseases. Not wearing a mask would put the nurse at risk of contracting varicella.

Choice D Reason:

“Only the client needs a mask” is incorrect because while it is important for the client to wear a mask to reduce the spread of infectious droplets, the nurse also needs to wear an N95 mask to protect themselves from airborne transmission.

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A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Edited TextA nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?

Correct Answer is C

Explanation

A nurse is caring for a client admitted with a rash. They are trying to rule out (r/o) varicella. Before entering the room, the nurse should be instructed to wear what kind of mask?

Correct Answer is A

Explanation

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