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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "You should ask your provider about your plan." This response is appropriate because it acknowledges the client's desire to explore alternative treatments while directing them to the appropriate source for medical advice. It promotes client autonomy and ensures they receive accurate information from their healthcare provider.
B. "Tell me what you know about chemotherapy." This response is also appropriate. It encourages the client to express their understanding and concerns about chemotherapy, allowing the nurse to identify any misconceptions and provide accurate information. This also opens the door for the client to express their concerns about vitamins and minerals, and why they want to persue that treatment.
C. "I have never heard of any holistic treatment that is effective." This response is inappropriate because it dismisses the client's preferences and demonstrates a lack of respect for their autonomy. It also displays a lack of knowledge, as some holistic treatments can be used as supportive therapies.
D. "The best way to treat your cancer is chemotherapy." This response is inappropriate because it is directive and does not allow the client to participate in decision-making. It also does not address the client's desire to explore alternative treatments.

A. Place pillows under the client's knee. B. Perform range-of-motion exercises on the client's knee. C. Apply an ice pack to the client's knee. D. Gently massage the area around the client's incision.

Correct Answer is C

Explanation

Applying an ice pack can help reduce pain and swelling after total knee arthroplasty.
Placing pillows under the client’s knee (choice A) is not recommended as it can hinder circulation and delay healing.
Performing range-of-motion exercises to the client’s knee (choice B) may be part of the rehabilitation process but should be done under the guidance of a physical therapist and may not be appropriate for immediate pain relief.
Gently massaging the area around the client’s incision (choice D) may not be appropriate as it can cause discomfort and disrupt the healing process.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cancer. The client tells the nurse, "I would prefer to try vitamins and minerals instead of chemotherapy." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium?

A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following?

A nurse is reviewing a cardiac rhythm strip of a client who has atrial flutter. Which of the following findings should the nurse expect?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The current infusion is almost complete and the new solution is not available, Which of the following actions should the nurse take?

A nurse is planning care for an older adult client who has Ménière's disease. Which of the following interventions should the nurse include in the plan?

A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?

A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when planning the client's meals?

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

Which of the following actions should the nurse take first?