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 C
Explanation
Choice A Reason:
Warfarin does not typically require a fasting state before blood is drawn for testing. The medication's effect on clotting factors is independent of food intake. Therefore, a fasting requirement is not anticipated for patients taking warfarin unless specified for other concurrent tests.
Choice B Reason:
There is no need for an alternate antiseptic due to warfarin use. Standard antiseptic procedures are sufficient when drawing blood from patients on warfarin. The choice of antiseptic would be more influenced by patient allergies or specific institutional protocols.
Choice C Reason:
Patients on warfarin have an increased bleeding time because the medication is an anticoagulant, which means it works to prevent blood clots by thinning the blood. This can lead to prolonged bleeding after a venipuncture, and phlebotomists should be prepared to apply pressure for a longer time to ensure hemostasis.
Choice D Reason:
Placing a specimen on ice is not a standard procedure for blood samples taken for warfarin monitoring, which is typically done through a PT/INR test. This test measures the time it takes for blood to clot and is not affected by temperature in the same way that tests for certain enzymes or gases might be.
Correct Answer is B
Explanation
Choice A Reason:
Shoe covers are used to protect the shoes and prevent the spread of contaminants from one area to another. They are not specifically required for droplet precautions during blood glucose monitoring. Droplet precautions typically focus on protecting mucous membranes of the eyes, nose, and mouth from droplet spatter.
Choice B Reason:
Masks are essential when dealing with patients under droplet precautions. Droplets can transmit infections when a person coughs, sneezes, or talks, and a mask provides a barrier that prevents the inhalation of these potentially infectious droplets. For procedures like blood glucose monitoring, where close contact with the patient is necessary, wearing a mask is crucial to protect both the healthcare worker and the patient.
Choice C Reason:
A gown is used to protect the healthcare worker's skin and clothing from contamination with potentially infectious material. While it is an important piece of personal protective equipment, it is not the primary requirement for droplet precautions in the context of blood glucose monitoring, unless there is a risk of substantial splashing or spraying of bodily fluids.
Choice D Reason:
Goggles are used to protect the eyes from splashes of blood or other body fluids. They are important in procedures where there is a risk of splashing, but for blood glucose monitoring, the risk is minimal. Therefore, goggles are not the primary piece of equipment required for droplet precautions in this scenario.
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