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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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. "I will use a mirror to inspect my feet daily." People with diabetes are at risk for nerve damage, which can lead to unnoticed foot injuries or infections. Using a mirror helps to inspect the feet daily and thoroughly, especially the soles, to prevent complications.

B. "I will eat a low residue diet." A low residue diet is not recommended for diabetes management. The focus for diabetic clients should be on balanced nutrition that controls blood glucose levels rather than restricting residue unless there are gastrointestinal issues.

C. "I will take my insulin 30 minutes before exercise." Taking insulin 30 minutes before exercise could increase the risk of hypoglycemia, especially if the exercise is vigorous. It is generally recommended to adjust insulin doses or carbohydrate intake depending on the type and intensity of the exercise, under the guidance of a healthcare provider.

D. "I will limit my fluid intake to 1 liter daily." Diabetes management does not involve limiting fluid intake unless there is a specific contraindication, such as kidney disease or heart failure. Adequate hydration is important for managing blood sugar levels and preventing dehydration.

Correct Answer is []

Explanation

Rationale for Correct Choices:

Left-sided heart failure: The client’s symptoms of dyspnea, fatigue with activity, heart palpitations, coughing at night, and bilateral crackles in the lung bases indicate left-sided heart failure. The fluid buildup in the lungs is a key feature of left-sided heart failure, causing symptoms like difficulty breathing and crackles on auscultation.
Administer a loop diuretic: Loop diuretics, like furosemide, help reduce fluid buildup in the lungs and peripheral tissues by increasing urine output. This is essential in left-sided heart failure, where fluid retention leads to symptoms such as dyspnea and crackles.
Administer morphine IV: Morphine is used in acute heart failure to relieve pain and anxiety, as well as to reduce preload and afterload. It helps to dilate blood vessels and can improve breathing by reducing the workload on the heart.
Lung sounds: Crackles in the bases of the lungs are indicative of fluid accumulation due to left-sided heart failure. Improvement or worsening of these crackles will indicate the effectiveness of the diuretic therapy and other interventions.
Pulse strength: Weak pulses (+1) may indicate poor perfusion due to heart failure. Monitoring changes in pulse strength can guide the nurse in assessing the client’s circulatory status and the response to treatment.

Rationale for Incorrect Choices:

Prepare the client for a valvuloplasty: Valvuloplasty is indicated for patients with valvular heart disease, typically involving the mitral or aortic valve. This client’s symptoms and diagnostic results suggest left-sided heart failure rather than a primary valve problem.
Obtain the client's temperature: The client's temperature (37.2°C) is within normal limits and does not indicate any fever or infection. Temperature monitoring is not a priority at this moment.
Assess the client's abdomen: Although abdominal distention and ascites are common in right-sided heart failure, the client's symptoms (dyspnea, crackles, and fatigue) are more indicative of left-sided heart failure. Abdominal assessment is not as critical in this scenario.
Mitral valve prolapse: Mitral valve prolapse often presents with palpitations, chest pain, and sometimes murmur, but it does not typically cause the same degree of fluid buildup and symptoms (dyspnea and crackles) as left-sided heart failure as seen in this patient.
Right-sided heart failure: This client's presentation is more consistent with left-sided heart failure. The primary symptoms of left-sided heart failure (dyspnea, fatigue, crackles, and lung congestion) are present, and no signs of right-sided heart failure (like edema or jugular venous distension) are noted.
Infective endocarditis: Infective endocarditis usually presents with fever, heart murmurs, and signs of infection, which are not evident in this case. The client’s symptoms suggest heart failure rather than an infectious process.
Heart sounds for systolic murmur: The heart sounds are noted as "clear" with an irregular rhythm, suggesting an arrhythmia rather than a structural heart problem that would typically cause a systolic murmur.
Blood culture results: Blood cultures would be necessary if there was a suspected infection, such as infective endocarditis, but there is no indication of infection in this client. The primary concern is heart failure, so blood cultures are not needed at this time.
Liver function tests: Liver function tests may be useful in cases of right-sided heart failure where hepatic congestion is common, but in left-sided heart failure, the priority is managing fluid retention and improving oxygenation.

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