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 C
Explanation
This is because furosemide is a diuretic that makes you pee more and lose water and electrolytes such as potassium and sodium.
Therefore, you should avoid foods that are high in sodium or potassium, such as bananas, oranges, cranberries, and bagels with cream cheese.
You should also drink plenty of fluids to prevent dehydration.
Choice A is wrong because oatmeal with a banana, milk, and orange juice contains too much potassium, which can cause irregular heartbeat or muscle weakness when taking furosemide.
Choice B is wrong because blueberry muffins, cranberry juice, and herbal tea contain too much sodium and sugar, which can raise your blood pressure and worsen your heart failure.
Choice D is wrong because a bagel with low-fat cream cheese and decaffeinated coffee contains too much sodium and caffeine, which can cause fluid retention and increase your heart rate.
Normal ranges for potassium are 3.5 to 5.0 mmol/L and for sodium are 135 to 145 mmol/L.
You should monitor your electrolyte levels regularly when taking furosemide.
Correct Answer is ["A","C","E"]
Explanation
Diazepam is a benzodiazepine that can cause central nervous system depression, which can manifest as decreased blood pressure, impaired physical coordination and respiratory depression. These signs and symptoms are consistent with benzodiazepine intoxication and may require treatment with flumazenil, a benzodiazepine receptor antagonist.
Choice B is wrong because increased temperature is not a sign of benzodiazepine intoxication. Benzodiazepines can cause hypothermia, or low body temperature, due to vasodilation and decreased metabolic rate.
Choice D is wrong because nausea and appetite loss are not signs of benzodiazepine intoxication. Benzodiazepines can cause gastrointestinal effects such as constipation, dry mouth and increased appetite.
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