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.

Establish an IV access.

Palpate for the client's carotid pulse

Apply a blood pressure cuff.

Answer and Explanation

The Correct Answer is C

A. Initiate cardiac monitoring for the client: Cardiac monitoring is important but should not occur before assessing the client's immediate circulatory status. Monitoring provides information about electrical activity but does not replace the need to confirm whether the client has a pulse, which determines the next steps in emergency care.

B. Establish an IV access: Establishing IV access is useful for administering emergency medications, but it should not occur until the nurse determines whether the client has a pulse. Interventions requiring vascular access are secondary to assessing airway, breathing, and circulation.

C. Palpate for the client's carotid pulse: The first priority in an unresponsive but breathing client is to assess circulation by checking for a carotid pulse. Determining whether the client has a pulse guides the nurse to initiate CPR if pulseless or continue supportive care if the pulse is present. This assessment directs all subsequent actions in the emergency response.

D. Apply a blood pressure cuff: Measuring blood pressure is part of a full assessment but is not the first action in an unresponsive client. Vital signs can be obtained after confirming pulse and ensuring that immediate life-threatening conditions are addressed.

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Correct Answer is B

Explanation

A. Three doses of nitroglycerin relieve the client's pain: Pain relieved by nitroglycerin suggests stable angina rather than an acute, unstable cardiac event. Although important to note, this finding does not indicate immediate danger compared to symptoms that suggest unstable or evolving myocardial ischemia.

B. Pain began in the morning while the client was resting: Chest pain occurring at rest is a hallmark of unstable angina and signals a high risk for myocardial infarction. Rest pain indicates reduced coronary perfusion independent of exertion, making this the most urgent finding requiring rapid intervention to prevent cardiac tissue damage.

C. Pain is greatest in the client's substernal chest area: Substernal pain is characteristic of angina, but this description alone does not differentiate between stable and unstable patterns. While clinically relevant, it is less critical than identifying ischemic pain that occurs without exertion.

D. Pain radiates to the client's left arm: Radiation to the left arm is a classic symptom of myocardial ischemia, but it does not inherently signal instability or immediate progression to infarction. Many clients with chronic stable angina experience similar radiation patterns, so this finding is not as urgent as rest-onset chest pain.

A. Clubbing of the fingers B. Pursed-lip breathing C. Dyspnea at rest D. Sa02; 92%

Correct Answer is C

Explanation

A. Clubbing of the fingers: Clubbing reflects long-term hypoxia and chronic lung disease progression, but it does not independently indicate the need for pulmonary rehabilitation. It is a structural change rather than a functional indicator of declining activity tolerance, so it does not guide referral decisions on its own.

B. Pursed-lip breathing: Pursed-lip breathing is a compensatory technique commonly used by clients with COPD to improve expiration and reduce air trapping. Its presence shows the client is already using adaptive methods, but it does not signal a new decline or a need for pulmonary rehabilitation.

C. Dyspnea at rest: Dyspnea at rest indicates significant functional impairment and poor exercise tolerance, which are key criteria for pulmonary rehabilitation referral. Pulmonary rehab helps clients who cannot maintain basic activity levels due to breathlessness by improving endurance, reducing dyspnea, and teaching energy-conservation strategies.

D. SaO₂ 92%: An oxygen saturation of 92% is common and generally acceptable in clients with COPD, as their baseline values are often lower than normal. This finding does not independently suggest declining function or worsening symptoms that would warrant a referral for pulmonary rehabilitation.

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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

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