A nurse finds an adult client lying unconscious & unresponsive on the bathroom floor. Which action should the nurse take first?

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.

This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.

Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.

The client may or may not need to use the bedpan depending on their fluid intake and output.

Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.

The client may or may not need to vomit depending on their underlying condition.

Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.