A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

Choice A reason: Referring a client because the unit is too busy is not an appropriate reason for a healthcare referral. Referrals should be based on the client’s specific needs and the expertise required to address those needs. Overcrowding or busyness of a unit should be managed through internal resources and staffing adjustments rather than referrals.

Choice B reason: When the care needed for the client is out of the healthcare provider’s scope of practice, a referral is necessary. This ensures that the client receives the appropriate level of care from a specialist or another provider with the required expertise. Referrals help in providing comprehensive and specialized care that the initial provider may not be equipped to deliver.

Choice C reason: Referring a client because they do not have insurance is not appropriate. Healthcare providers should assist clients in finding resources and support for their care needs, regardless of their insurance status. Referrals should be based on clinical needs, not financial or insurance considerations.

Choice D reason: Referring a client because they are late is not a valid reason for a healthcare referral. Timeliness is important, but it should not determine the need for a referral. Providers should address the reasons for lateness and work with the client to ensure they receive the necessary care.

Choice A reason: Starting chest compressions is the priority intervention for a client who is unresponsive, not breathing, and without a pulse. This situation indicates cardiac arrest, and immediate chest compressions are crucial to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions improves the chances of survival and neurological outcomes.

Choice B reason: Obtaining a central line is not an immediate priority in the context of cardiac arrest. While central lines are important for administering medications and fluids, the first step in resuscitation is to establish effective chest compressions. Central line placement can be considered after initial resuscitation efforts are underway.

Choice C reason: Completing a comprehensive assessment is important, but it is not the immediate priority in a cardiac arrest situation. The primary focus should be on initiating chest compressions and basic life support measures. A detailed assessment can be performed once the client is stabilized.

Choice D reason: Providing rescue breathing is part of cardiopulmonary resuscitation (CPR), but it should follow the initiation of chest compressions. Current guidelines emphasize the importance of starting chest compressions immediately and then integrating rescue breaths. Effective chest compressions are the foundation of CPR.