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 D
Explanation
30 to 40 mL/hour. This is the normal range of urine output for a typical adult client. The urine output should be at least 0.5 mL/kg/hour for adults.
Assuming an average weight of 70 kg, this would be 35 mL/hour.
Choice A is wrong because 5 to 10 mL/hour is too low and indicates oliguria, which is a sign of inadequate kidney function or dehydration.
Choice B is wrong because 12 to 15 mL/hour is also below the normal range and may indicate oliguria.
Choice C is wrong because 16 to 25 mL/hour is slightly below the normal range and may indicate reduced kidney perfusion or fluid intake.
Correct Answer is C
Explanation
This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.
Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.
Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.
This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.
Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.
This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.
Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.
Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.
However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.
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