The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

Blood pressure.

Temperature.

Respiratory rate.

Pulse rate.

Answer and Explanation

The Correct Answer is C

Choice A: Blood pressure is not the first vital sign to obtain because it is not as sensitive to changes in the level of consciousness as respiratory rate. Blood pressure may be normal or elevated in some cases of decreased consciousness, such as stroke or head injury.

Choice B: Temperature is not the first vital sign to obtain because it is not as relevant to the level of consciousness as respiratory rate. Temperature may be normal or slightly elevated in some cases of decreased consciousness, such as infection or dehydration.

Choice C: Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity.

Choice D: Pulse rate is not the first vital sign to obtain because it is not as indicative of the level of consciousness as respiratory rate. Pulse rate may be normal, fast, or slow in cases of decreased consciousness, depending on the cause and compensatory mechanisms.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A Reason: This is correct because hospice provides comfort, dignity, and emotional support to clients with terminal illnesses and their families. Hospice focuses on palliative care rather than curative treatment.

Choice B Reason: This is correct because hospice can be provided within comforts of home or in other settings such as nursing homes or hospice facilities. Hospice allows clients to die in their preferred environment.

Choice C Reason: This is correct because hospice services can be initiated prior to discharge from the hospital or at any time during the course of the illness. Hospice requires a physician's order and a prognosis of six months or less to live.

Choice D Reason: This is correct because family members can be involved in the plan of care and receive education, counseling, and bereavement support from hospice staff. Hospice promotes family-centered care and respects cultural and spiritual preferences.

Choice E Reason: This is incorrect because a living will remains valid when receiving hospice care. A living will is a legal document that expresses the client's wishes regarding life-sustaining treatments in case of incapacity.

A. Notify the healthcare provider. B. Document the event on the chart. C. Complete an incident report. D. Inform the nurse on the next shift.

Correct Answer is A

Explanation

Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.

Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.

Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.

Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.

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The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

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