A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?

Starting chest compressions

Obtaining a central line

Completing a comprehensive assessment

Providing rescue breathing

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

Choice A reason: Applying compression stockings is a key prophylactic intervention to prevent complications of immobility, such as deep vein thrombosis (DVT) and venous thromboembolism (VTE). Compression stockings help improve blood circulation in the legs by applying graduated pressure, which reduces the risk of blood clots forming in the deep veins. This is particularly important for immobile patients who are at higher risk of developing DVT due to prolonged periods of inactivity.

Choice B reason: Raising all side rails is primarily a safety measure to prevent falls and does not directly address the complications of immobility. While it is important for patient safety, it does not have a significant impact on preventing issues like DVT, pressure ulcers, or muscle atrophy. Therefore, it is not considered a prophylactic intervention for immobility-related complications.

Choice C reason: Inserting a urinary catheter is not a prophylactic intervention for preventing complications of immobility. Catheters are used to manage urinary retention or incontinence but can increase the risk of urinary tract infections (UTIs) if not managed properly. They do not address the primary complications associated with immobility, such as DVT or pressure ulcers.

Choice D reason: Using friction-reducing devices is important for preventing pressure ulcers and skin injuries in immobile patients. These devices help minimize friction and shear forces on the skin, which can lead to pressure ulcers. While this is a valuable intervention, it is not as comprehensive as compression stockings in preventing a range of immobility-related complications.

A. Encourage the patient to drink more fluids. B. Get a prescription for an antitussive agent. C. Teach effective deep breathing. D. Change the patient’s position every 2 hours.

Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.

Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.

Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.

Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.

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A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile. Which prophylactic intervention would be used to prevent complications of immobility?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

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