The nurse walks in to bring a patient’s medications. She finds the patient unconscious and after a tap and shout realizes the patient is unresponsive. Which intervention has the highest priority?
Check for a carotid pulse for one full minute.
Check for an apical pulse for 30 seconds.
Count the radial pulse for one full minute.
Check for a carotid pulse for no longer than 10 seconds.
The Correct Answer is D
Choice A reason: Checking for a carotid pulse for one full minute is inappropriate in an emergency because it delays initiation of CPR. Pulse checks should be brief to avoid wasting critical time.
Choice B reason: Checking an apical pulse for 30 seconds is not appropriate in an unresponsive patient. Apical pulse assessment is used for routine monitoring, not emergency situations.
Choice C reason: Counting the radial pulse for one full minute is inappropriate because radial pulses may be absent in cardiac arrest, and this delays life-saving interventions.
Choice D reason: This is the correct action because in an unresponsive patient, the nurse should check for a carotid pulse for no longer than 10 seconds. If no pulse is detected, CPR should be initiated immediately. This aligns with current resuscitation guidelines, which emphasize minimizing delays in chest compressions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Wearing gloves to empty a urinal is appropriate infection control practice. Gloves protect the nurse from exposure to urine and potential pathogens.
Choice B reason: Cleansing hands with hand gel before entering a patient room is acceptable for most situations. Alcohol-based hand rubs are effective against many pathogens, though not against C. Diff spores.
Choice C reason: Washing hands with soap and water for only 10 seconds is insufficient. Proper hand hygiene requires at least 20 seconds of scrubbing to effectively remove pathogens. Inadequate handwashing increases infection transmission.
Choice D reason: Wearing artificial nails during patient care increases infection risk because bacteria and fungi can harbor under artificial nails, even with hand hygiene. This practice is prohibited in clinical settings.
Choice E reason: Using hand gel after caring for a patient with C. Diff is ineffective because alcohol-based sanitizers do not kill C. Diff spores. Soap and water must be used to prevent transmission.
Correct Answer is A
Explanation
Choice A reason: Patients on anticoagulants are at increased risk of bleeding because their clotting ability is impaired. Using a traditional razor could cause cuts that bleed excessively and are difficult to control. An electric razor minimizes the risk of nicks and cuts, making it the safest option for these patients. This is the evidence-based standard of care when shaving patients on blood thinners.
Choice B reason: Being unconscious does not require the use of an electric razor. The choice of razor depends on bleeding risk, not consciousness level. While unconscious patients need careful handling, a standard razor could still be used if they are not at risk for bleeding complications.
Choice C reason: Having a full beard does not necessitate an electric razor. Beard removal can be done with clippers or a traditional razor depending on patient preference and safety considerations. The presence of a beard alone is not a clinical reason to avoid a standard razor.
Choice D reason: Patients with lice require specialized treatment such as medicated shampoos or lice removal protocols, not shaving with an electric razor. Shaving does not eliminate lice and is not considered appropriate care.
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