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

Apply a blood pressure cuff.

Establish an IV access.

Palpate for the client's carotid pulse.

Initiate cardiac monitoring for the client.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Apply a blood pressure cuff: Applying a blood pressure cuff is not the first priorit. The nurse’s first priority should be assessing the client’s circulation and responsiveness. Blood pressure measurement can be done after confirming the client's pulse and overall condition.

B. Establish an IV access: While establishing an IV access may be necessary for medication administration or fluid resuscitation, the immediate concern is assessing the client’s airway, breathing, and circulation. IV access should be obtained after ensuring that these basic life-sustaining functions are stable.

C. Palpate for the client's carotid pulse: The first step in evaluating an unresponsive client who is breathing is to check for a pulse to assess circulation. The nurse should palpate the carotid pulse to determine whether the client has a pulse and is adequately perfusing.

D. Initiate cardiac monitoring for the client: Cardiac monitoring is important, but it is not the first action to take when a client is unresponsive. The nurse should first assess the client’s pulse and breathing to ensure they are receiving adequate circulation before monitoring.

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 []

Explanation

Rationale for Correct Choices:

Hyperthyroidism: The client's symptoms—including a high fever, chest pain, palpitations, tremors, tachycardia, weight loss, diarrhea, and hyperactive bowel sounds—are indicative of hyperthyroidism. The lab results showing elevated T3 and T4 with suppressed TSH further support this diagnosis..
Place client on telemetry: Given the client's tachycardia (heart rate of 125/min), chest pain, and potential for arrhythmias (a common complication of hyperthyroidism), placing the client on telemetry is essential to monitor for any cardiac dysrhythmias.
Initiate hydration therapy: Hyperthyroidism can lead to dehydration due to increased metabolic activity and diarrhea. The client has reported weight loss and diarrhea, indicating the need for fluid replacement.
Cardiac dysrhythmias: Hyperthyroidism often causes tachycardia and increases the risk of arrhythmias, especially atrial fibrillation. Monitoring for cardiac dysrhythmias is crucial in this case to ensure the client’s heart rhythm is stable and to prevent complications.
Neurological Status: The client is oriented x 3 but appears nervous, agitated, and has tremors. In thyroid storm, severe agitation, delirium, psychosis, and even coma can develop. Close monitoring of neurological status is essential to assess the severity of encephalopathy.

Rationale for Incorrect Choices:

Hypoparathyroidism: Hypoparathyroidism typically causes symptoms such as muscle spasms, tetany, and hypocalcemia, which do not match the client’s presentation. The client has symptoms more consistent with hyperthyroidism.
Hypothyroidism: Hypothyroidism is characterized by fatigue, weight gain, bradycardia, and cold intolerance, which is the opposite of what the client is presenting with. The lab results (elevated T3 and T4 levels) also exclude hypothyroidism as a possibility.
Hyperparathyroidism: Hyperparathyroidism typically presents with hypercalcemia, muscle weakness, and fatigue. The client’s calcium levels are normal (9.5 mg/dL) and the clinical symptoms are more indicative of hyperthyroidism, not hyperparathyroidism.
Provide nutritional support: While nutritional support may be needed for managing hyperthyroidism long-term, it is not the priority action in this acute setting. Immediate interventions should focus on stabilizing the patient’s heart rate and fluid balance.
Check for Chvostek and Trousseau signs: Chvostek and Trousseau signs are used to assess for hypocalcemia, which is more relevant to conditions like hypoparathyroidism. In this case, hyperthyroidism is more likely, and these signs would not be helpful in this scenario.
Monitor for hypoglycemia: While endocrine disorders can sometimes have overlapping symptoms or comorbidities, there's no specific indication or direct risk for hypoglycemia from hyperthyroidism in this presentation.
Phosphorus levels: Phosphorus levels are typically monitored in cases involving kidney function, bone metabolism, or certain endocrine disorders like hypoparathyroidism or hyperparathyroidism, not hyperthyroidism.
Weight gain: Weight gain is not relevant in the context of hyperthyroidism, where the typical presentation includes weight loss despite an increased appetite. Monitoring weight gain would be more appropriate in cases of hypothyroidism.
Calcium levels: The client's calcium level is currently normal. While thyroid conditions can sometimes affect calcium, it's not the primary or most dynamic parameter to monitor for the acute phase and progress of thyroid storm compared to vital signs and mental status

A. Strict I&O B. Increase fluid intake C. Encourage protein supplements D. Strain all urine

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

Explanation

Rationale:

A. Strict I&O: Monitoring intake and output is essential due to decreased urination, flank pain, and impaired kidney function. The elevated BUN and creatinine levels suggest renal impairment, and strict I&O helps assess fluid balance.

B. Increase fluid intake: While hydration is important, increasing fluids should be done cautiously due to the client’s impaired kidney function. Given the elevated BUN and creatinine, the kidneys may not manage increased fluids without worsening fluid retention.

C. Encourage protein supplements: Protein supplements are not recommended in kidney dysfunction, as they can worsen renal strain. Elevated BUN and creatinine levels indicate kidney impairment, and protein intake may aggravate the condition.

D. Strain all urine: Straining all urine is necessary to capture any possible kidney stones, blood clots, or debris. The reddish-brown urine and positive blood in the urinalysis suggest hematuria, which may need further investigation.

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

Correct Answer is []

Explanation

The nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse perform?

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

Explanation

A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the lists of options. The nurse should administer a total of dropdown 0.9% sodium chloride in the first hour, and then dropdown subsequent hour.

A nurse is providing teaching to a client who has diabetes mellitus. Which of the following instructions should the nurse provide to the client to help prevent the development of nephropathy?

A nurse is caring for a client who is 4 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

A nurse is teaching a client who has burns to the upper body about positioning to prevent contractures. Which of the following information should the nurse include?

A nurse is providing discharge teaching to a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?