A client is unresponsive.
Which of the following nursing actions is the priority?

Assessing the client's level of pain.

Checking the client's airway and breathing.

Documenting the client's Glasgow Coma Scale score.

Obtaining a detailed neurological history from family.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Assessing the client's level of pain is important in many situations, but in an unresponsive client, airway and breathing take immediate priority. An unresponsive client cannot communicate pain, and addressing potentially life-threatening issues like airway obstruction or respiratory arrest is paramount.

Choice B rationale

Checking the client's airway and breathing is the priority nursing action for an unresponsive client. Unresponsiveness can indicate a critical condition that may compromise the client's ability to maintain a patent airway or breathe effectively. Ensuring a clear airway and adequate ventilation are essential for preventing hypoxia and death. This aligns with the ABC (Airway, Breathing, Circulation) approach to emergency care.

Choice C rationale

Documenting the client's Glasgow Coma Scale (GCS) score is important for assessing the level of consciousness and neurological function. However, in an unresponsive client, ensuring airway and breathing precedes a detailed neurological assessment. The GCS can be assessed after immediate life-threatening issues are addressed.

Choice D rationale

Obtaining a detailed neurological history from family can provide valuable information, but it is not the priority in the immediate management of an unresponsive client. Addressing the client's immediate physiological needs, such as airway and breathing, takes precedence over gathering historical information.

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Correct Answer is A

Explanation

Choice A rationale

Headache is a common and expected adverse effect of nitroglycerin. Nitroglycerin causes vasodilation, including dilation of the cerebral blood vessels. This increased blood flow to the head is the primary physiological mechanism responsible for nitroglycerin-induced headaches.

A. Oxygen. B. Aspirin. C. Nitroglycerin. D. Morphine.

Correct Answer is D

Explanation

Choice A rationale

Oxygen is crucial in the initial management of an acute myocardial infarction to address hypoxemia that may result from decreased cardiac output and impaired tissue perfusion. Supplemental oxygen aims to maintain adequate arterial oxygen saturation, typically above 90%, to support oxygen delivery to the ischemic myocardium and other vital organs. While important, it primarily addresses oxygenation rather than directly managing pain and anxiety in the post-acute phase.

Choice B rationale

Aspirin is a cornerstone of immediate management for acute myocardial infarction due to its antiplatelet properties. It inhibits thromboxane A2, reducing platelet aggregation and thrombus formation, thereby improving coronary artery patency. However, its primary role is in preventing further clot formation and reducing mortality, not in directly managing pain and anxiety after the acute phase.

Choice C rationale

Nitroglycerin is administered to patients with acute myocardial infarction to alleviate chest pain through vasodilation. It reduces preload and afterload, decreasing myocardial oxygen demand and increasing coronary blood flow. While effective for acute pain, its use for routine pain and anxiety management after the initial acute phase is less common compared to medications with direct analgesic and anxiolytic effects.

Choice D rationale

Morphine sulfate is an opioid analgesic commonly used in the management of acute myocardial infarction to relieve severe chest pain. Beyond its analgesic properties, morphine also has a mild sedative effect, which can help reduce anxiety associated with the cardiac event. Its administration helps to decrease sympathetic nervous system activity, reducing myocardial workload and oxygen demand in the post-acute phase when pain and anxiety may persist.

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A client is unresponsive. Which of the following nursing actions is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain.The client reports relief from the chest pain but now he is experiencing a headache.Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

Correct Answer is D

Explanation

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A client is unresponsive.
Which of the following nursing actions is the priority?