A nurse finds an adult client lying unconscious & unresponsive on the bathroom floor. Which action should the nurse take first?
Call for assistance.
Give 2 rescue breaths.
Check for apical pulse.
Begin chest compressions.
The Correct Answer is A
This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.
Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.
Giving rescue breaths to a client who has a pulse may cause harm.
Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.
Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.
Chest compressions may cause harm to a client who has a pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
These are some of the common symptoms of hypothyroidism, which is a condition where the thyroid gland does not produce enough thyroid hormones. Thyroid hormones regulate the body’s metabolism, temperature and heart rate.
Choice A is wrong because a pulse of 126 is too high for hypothyroidism. Hypothyroidism usually causes a slow heart rate (bradycardia), not a fast one (tachycardia). A normal resting pulse rate for adults is between 60 and 100 beats per minute.
Choice E is wrong because a pulse of 54 is within the normal range for
hypothyroidism. Hypothyroidism can cause a pulse rate lower than 60 beats per minute, but this is not always abnormal. Some people, such as athletes, may have a lower resting pulse rate due to their fitness level.
The normal ranges for thyroid function tests are:
- Thyroid-stimulating hormone (TSH): 0.4 to 4.0 milli-international units per liter (mIU/L).
- Free thyroxine (T4): 0.8 to 2.8 nanograms per deciliter (ng/dL).
- Total triiodothyronine (T3): 80 to 220 ng/dL.
Correct Answer is A
Explanation
Formed stool two times per day, every day, for one week. This indicates that bowel training is attaining the desired outcome because it shows regularity and consistency of bowel movements without the use of laxatives or enemas.
Choice B is wrong because soap sud enemas are not recommended for bowel training as they can irritate the bowel and cause fluid and electrolyte imbalance.
Choice C is wrong because continued use of laxatives can inhibit the natural defecation reflexes and cause dependency.
Choice D is wrong because a formed, soft stool at regular intervals without the use of a laxative is a normal defecation pattern, not an indication of fecal incontinence.
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