A phlebotomist enters a patient's room and observes the patient to be motionless and cyanotic. Which of the following actions should the phlebotomist take first?
Ask the patient if they are okay in a loud voice.
Perform the head-tilt-chin-lift maneuver.
Administer two rescue breaths.
Look, listen, and feel for breathing movements.
The Correct Answer is A
Choice A reason:
When encountering a patient who appears motionless and cyanotic, the first action should be to assess their level of consciousness. Asking loudly if they are okay can help determine if the patient is responsive or unresponsive. If there is no response, this indicates that the patient may be unconscious and requires further immediate assessment and potential intervention.
Choice B reason:
The head-tilt-chin-lift maneuver is used to open the airway of an unresponsive patient who is not suspected of having a spinal injury. However, this is not the first step. Before performing any maneuvers, it is essential to determine the patient's level of consciousness and whether they are breathing.
Choice C reason:
Administering rescue breaths is part of the process of cardiopulmonary resuscitation (CPR), which is only initiated after confirming that the patient is unresponsive and not breathing normally. This step comes after checking for responsiveness and breathing.
Choice D reason:
Looking, listening, and feeling for breathing movements is part of the assessment to determine if the patient is breathing normally. This is done after establishing unresponsiveness but before initiating CPR. It is a critical step, but it follows after confirming that the patient does not respond to verbal stimuli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Inverting the tube 5 to 8 times ensures that the clot activator mixes thoroughly with the blood, promoting proper clotting. Setting the tube aside for 30 minutes allows sufficient time for the blood to clot before centrifugation. This is the recommended procedure to ensure that the serum is properly separated from the clot, resulting in a quality specimen suitable for testing.
Choice B reason:
Inverting the tube only 1 to 3 times may not be enough to mix the clot activator with the blood adequately, which could lead to incomplete clotting and potentially compromised test results. Additionally, setting the tube for 1 hour before centrifugation is longer than necessary and does not offer any advantage over the recommended 30 minutes.
Choice C reason:
Inverting the tube 2 to 4 times might not fully mix the clot activator with the blood, and setting it for only 15 minutes does not provide enough time for proper clot formation. This could result in a suboptimal separation of serum and clot, affecting the integrity of the test results.
Choice D reason:
Inverting the tube 8 to 10 times could potentially cause hemolysis or disruption of the blood cells due to excessive agitation. Setting the tube for 2 hours prior to centrifugation is not recommended as it could lead to serum degradation or other changes that may affect the test results.
Correct Answer is D
Explanation
Choice A reason:
Heparin is an anticoagulant, not a clot activator. It works by inhibiting thrombin and preventing the conversion of fibrinogen to fibrin, thus preventing clot formation. It is commonly found in green-top tubes and is suitable for collecting plasma samples for tests like electrolyte levels and coagulation studies.
Choice B reason:
Oxalate is also an anticoagulant that prevents clotting by precipitating calcium. It is not used to promote clot formation but rather to maintain a blood sample in a non-coagulated state for various tests.
Choice C reason:
Citrate functions similarly to heparin and oxalate as an anticoagulant. It chelates calcium ions in the blood, inhibiting the coagulation process. Citrate is often used in blue-top tubes and is ideal for collecting plasma samples for coagulation studies.
Choice D reason:
Silica is a clot activator. It is commonly used in serum separator tubes (SSTs) with a gold or red speckled top. The silica particles provide a surface for the rapid formation of the clot, allowing for the separation of serum from the blood cells. This is essential when serum is needed for testing.
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