A nurse finds a client in bed, unresponsive and breathing.

Which of the following actions should the nurse take first?

Initiate cardiac monitoring for the client.

Apply a blood pressure cuff.

Palpate for the client's carotid pulse.

Establish an IV access.

Answer and Explanation

The Correct Answer is C

The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.

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Correct Answer is D

Explanation

A pneumothorax is a collapsed lung that occurs when air leaks into the space between the lung and the chest wall.
This can cause diminished breath sounds on the affected side. Distended neck veins are not a symptom of pneumothorax.
B) Itching over the incision is not a symptom of pneumothorax.
C) Irregular heart rate is not a symptom of pneumothorax.

A. Poor skin turgor. B. Pitting edema. C. Oliguria. D. S4 galloping heart sounds.

Correct Answer is B

Explanation

Pitting edema is a common and obvious symptom of right-sided heart failure.

This occurs when fluid retention causes swelling in the lower limbs and sometimes the abdomen.
Choice A is incorrect because poor skin turgor is not a common symptom of right-sided heart failure.
Choice C is incorrect because oliguria, or decreased urine output, is not a common symptom of right-sided heart failure.
Choice D is incorrect because S4 galloping heart sounds are not a common symptom of right-sided heart failure.

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A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first?

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A nurse finds a client in bed, unresponsive and breathing.

Which of the following actions should the nurse take first?