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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
When calculating the fluid balance for a client undergoing continuous bladder irrigation (CBI), the irrigation solution must be deducted from the total urine output. This is because the irrigation fluid is not part of the client’s actual urine production but is an additional fluid introduced into the bladder to prevent or remove blood clots and ensure catheter patency. By deducting the irrigation solution from the total urine output, the nurse can accurately determine the client’s true urine output and fluid balance.
Choice B Reason:
Subtracting the irrigation solution from the intravenous flow sheet as output is incorrect. The intravenous flow sheet is used to document fluids administered intravenously, not those introduced into the bladder. Therefore, this choice does not apply to the management of continuous bladder irrigation.
Choice C Reason:
Documenting the intake hourly in the urine output column is also incorrect. The urine output column should reflect the actual urine produced by the client, not the irrigation solution. Including the irrigation solution in this column would lead to an inaccurate representation of the client’s urine output and fluid balance.
Choice D Reason:
Adding the irrigation solution to the oral intake column is incorrect as well. The oral intake column is designated for fluids consumed orally by the client. The irrigation solution is introduced directly into the bladder and should not be recorded as oral intake.
Correct Answer is C
Explanation
Choice A Reason:
Asking “When did you begin to have trouble sleeping?” is important for understanding the onset and duration of the client’s insomnia. However, it does not directly address immediate safety concerns. Chronic insomnia can lead to significant daytime impairment, but the question about the onset of sleep troubles does not identify specific safety risks.
Choice B Reason:
Inquiring about specific factors affecting the client’s ability to sleep can help identify potential causes of insomnia, such as stress, environmental factors, or medical conditions. While this information is valuable for treatment planning, it does not directly address immediate safety concerns.
Choice C Reason:
Asking “Do you have difficulty staying awake when you are driving?” addresses the highest safety priority. Chronic insomnia can lead to excessive daytime sleepiness, which significantly increases the risk of accidents, especially while driving. Identifying whether the client is at risk of falling asleep during potentially dangerous activities is crucial for immediate safety.
Choice D Reason:
Understanding the client’s bedtime routine can provide insights into their sleep hygiene and habits, which are important for managing insomnia. However, this question does not directly address immediate safety concerns related to daytime functioning and the risk of accidents.
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