A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?

Administer rescue breathing.

Open the client's airway.

Begin chest compressions.

Activate a code blue.

Answer and Explanation

The Correct Answer is C

A. Administering rescue breathing is important in providing oxygen to the client, but without circulation provided by chest compressions, oxygen will not effectively reach vital organs. In adult cardiac arrest, immediate chest compressions are the first priority to maintain blood flow to the brain and heart.
B. Opening the client's airway is an essential component of basic life support but comes after initiating chest compressions in the current guidelines. Prioritizing airway over circulation delays the delivery of critical perfusion necessary to preserve organ function during cardiac arrest.
C. Beginning chest compressions is the first action because effective compressions circulate oxygenated blood to vital organs, improving the chance of survival. The American Heart Association emphasizes "CAB" (Circulation, Airway, Breathing) for adults, starting with compressions to minimize delays in restoring circulation.
D. Activating code blue is critical to summon additional help, but it should be done simultaneously if possible or immediately after starting chest compressions. Delaying compressions to call for help compromises perfusion and decreases the client’s chances of successful resuscitation.

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

Explanation

A. Assessing legs for redness is essential because redness, warmth, and swelling are early signs of deep vein thrombosis (DVT), which can lead to a pulmonary embolism. Early detection allows for prompt intervention before the clot dislodges and travels to the lungs.
B. Performing passive range of motion exercises promotes venous return in immobile clients, reducing the risk of blood stasis and clot formation. Passive movement simulates the muscle activity that normally helps propel blood through the veins, lowering DVT and PE risk.
C. Massaging the calves every shift is contraindicated because massaging the calves can dislodge an existing clot, increasing the risk of pulmonary embolism. Instead of promoting circulation safely, it could trigger a life-threatening complication by mobilizing a thrombus.
D. Applying elastic compression stockings helps prevent venous stasis by applying consistent pressure to the legs, thereby promoting venous return and reducing the risk of DVT formation. This mechanical prophylaxis is a standard measure to prevent PE in immobile clients.

A. A client who has severe respiratory stridor and a deviated trachea B. A client who has a small circular partial thickness burn of the left calf C. A client who has a massive head injury and is experiencing seizures D. A client who has a splinted open fracture of left medial malleolus

Correct Answer is A

Explanation

A. A client who has severe respiratory stridor and a deviated trachea must be assessed first because this indicates a life-threatening airway obstruction, possibly from a tension pneumothorax. Immediate intervention is required to secure the airway and prevent complete respiratory failure and death.
B. A client who has a small circular partial thickness burn of the left calf is stable and can be safely delayed for later treatment. Partial-thickness burns on a small area of the body do not pose an immediate threat to life or limb.
C. A client who has a massive head injury and is experiencing seizures is critical, but massive head trauma with ongoing seizures often has a poor prognosis, and during a mass casualty event, resources are prioritized for those with the best chances of survival with intervention.
D. A client who has a splinted open fracture of the left medial malleolus is stable after splinting and does not require immediate life-saving measures. Orthopedic injuries without severe bleeding can generally wait for definitive treatment.

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A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?

Nursing Test Bank

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