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

Call the rapid response team.

Move the client to the bed.

Call the primary care provider.

Assess client for unresponsiveness.

Answer and Explanation

The Correct Answer is D

This is because the nurse should always follow the ABC (airway, breathing, circulation) priority when dealing with a client who suddenly slumps over. The nurse should check if the client is conscious and breathing before calling for help or moving the client.

Choice A is wrong because calling the rapid response team should not be done before assessing the client’s condition and ensuring a patent airway.

Choice B is wrong because moving the client to the bed may cause further harm or aspiration if the client has food in the mouth or airway.

Choice C is wrong because calling the primary care provider is not a priority action in this situation. The nurse should first assess and stabilize the client before notifying the provider.

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Correct Answer is A

Explanation

Maintain trust and avoid behaviors that may increase agitation. This is the priority action because it is important for the nurse to attempt to de-escalate the client and maintain trust.

A. Ordering the client to go to their room and alerting security is not the priority action because it may increase agitation and does not maintain trust.

C. Telling the client to sit down or risk isolation and loss of privileges is not the priority action because it may increase agitation and does not maintain trust.

D. Sedating the client after collecting a lithium level is not the priority action because it does not address the immediate need to de-escalate the situation and maintain trust.

A. Rhonchi. B. Wheezing. C. Crackles. D. Pleural friction rub.

Correct Answer is A

Explanation

Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.

Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.

Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.

Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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