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.

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Correct Answer is ["A","C","D","E","G","I"]

Explanation

Rationale for Correct Choices:

A. Cardiac findings: The client has signs of fluid retention, including jugular vein distention (JVD) and periorbital edema, suggesting potential heart failure. Monitoring the heart and assessing for potential complications such as arrhythmias or decreased cardiac output is necessary.

B. Neurologic assessment: The client is alert and oriented to person, place, and time, with no signs of confusion or altered mental status. Neurological assessment does not need to be prioritized at this time.

C. Temperature: The elevated temperature of 38.8°C (101.8°F) could indicate an underlying infection. Given the client's recent history of strep throat and the signs of infection in the urine (positive nitrites and leukocyte esterase), a urinary tract infection (UTI) could be a potential cause for the fever.

D. Respiratory characteristics: The client has crackles bilaterally, labored breathing, and low oxygen saturation (90% on room air), which suggest respiratory distress. These findings need further follow-up.

E. Urinalysis: The urinalysis shows dark red color (indicative of hematuria), positive nitrites, positive leukocyte esterase, and blood in the urine. These results suggest a urinary tract infection (UTI) and possible kidney involvement. The reddish-brown urine may also require further assessment to rule out hemolysis or muscle injury.

F. Cardiac rhythm: The client’s heart rhythm is described as normal sinus rhythm (NSR) with a rate of 88/min. There are no immediate concerns about arrhythmias at this time, and the heart rate is within normal limits.

G. Breath sounds: The presence of crackles on auscultation in both lungs indicates possible pulmonary edema or fluid overload, which is commonly seen in heart failure. Follow-up is required to assess for worsening respiratory status and need for intervention.

H. Bowel sounds: The client's bowel sounds are normal, with no signs of gastrointestinal distress or obstruction. There is no indication of a problem in the GI system.

I. Respiratory rate: The client's respiratory rate is 26/min, which is elevated. This, combined with shortness of breath and labored respirations, indicates significant respiratory distress. It is a key indicator of impaired gas exchange or increased work of breathing.

A. Hematochezia B. Elevated hemoglobin C. Weight gain D. Steatorrhea

Correct Answer is A

Explanation

Rationale:

A. Hematochezia: The passage of fresh blood in the stool, is a common symptom of colon cancer, especially when the tumor is located in the lower colon or rectum. Results from bleeding from the tumor and should be monitored in clients with a new diagnosis.

B. Elevated haemoglobin: An elevated hemoglobin level is not typical in colon cancer. Colon cancer often leads to chronic blood loss, which can cause anemia and result in a low hemoglobin level rather than an elevated one.

C. Weight gain: Weight loss, rather than weight gain, is more commonly seen in clients with colon cancer due to decreased appetite, malabsorption, or the metabolic effects of the cancer. Weight gain is not a typical finding associated with colon cancer.

D. Steatorrhea: Steatorrhea, or fatty stools, is more commonly associated with pancreatic or biliary disease rather than colon cancer. While colon cancer can cause digestive disturbances, steatorrhea is not typically expected.

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