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 C

Explanation

Choice A reason: While chest physiotherapy can help mobilize secretions, it does not specifically promote the flow of secretions to the base of the lungs. The primary goal is to loosen and mobilize secretions so they can be coughed up and cleared from the airways. This helps improve overall lung function and oxygenation.

Choice B reason: Chest physiotherapy does not eliminate the need to cough. In fact, coughing is an essential part of the process as it helps expel the loosened secretions from the airways. The therapy aims to make coughing more effective by loosening the mucus.

Choice C reason: The primary purpose of chest physiotherapy with percussion and vibration is to help clear the airways of excessive secretions. This is particularly important for patients with conditions like chronic obstructive pulmonary disease (COPD), cystic fibrosis, or pneumonia, where mucus buildup can obstruct the airways and impair breathing. By loosening and mobilizing the secretions, the therapy facilitates their removal through coughing.

Choice D reason: Chest physiotherapy does not limit the production of bronchial mucus. It focuses on clearing existing mucus from the airways rather than reducing its production. The production of mucus is influenced by underlying conditions and may require other treatments to manage.

A. Cured fat food B. Vegetables C. Canned soups D. Processed snacks E. Sugary drinks

Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Cured fat foods, such as bacon, sausages, and other processed meats, are high in saturated fats and sodium. Consuming these foods in excess can lead to increased cholesterol levels and a higher risk of heart disease. Limiting these foods is essential for maintaining a healthy diet and reducing the risk of chronic diseases.

Choice B Reason:

Vegetables are generally low in calories and high in essential nutrients, including vitamins, minerals, and fiber. They are an important part of a balanced diet and should not be limited. Instead, increasing vegetable intake is often recommended for better health outcomes.

Choice C Reason:

Canned soups often contain high levels of sodium, which can contribute to high blood pressure and other cardiovascular issues. Limiting the intake of canned soups can help manage sodium consumption and promote better heart health.

Choice D Reason:

Processed snacks, such as chips, crackers, and packaged baked goods, are typically high in unhealthy fats, sugars, and sodium. These foods can contribute to weight gain, high blood pressure, and other health problems. Reducing the intake of processed snacks is beneficial for overall health.

Choice E Reason:

Sugary drinks, including sodas, fruit juices with added sugars, and energy drinks, are high in calories and can lead to weight gain and increased risk of type 2 diabetes. Limiting sugary drinks is crucial for maintaining a healthy weight and preventing chronic diseases.

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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 primary health care provider orders chest physiotherapy with percussion and vibration for a client. After the health care provider leaves, the client says, “I still don’t understand the purpose of this therapy.” Which statement should be included in the nurse’s response?

Correct Answer is C

Explanation

The nurse is providing education to a client about nutrition. Which foods should the client be instructed to limit in their diet? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

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