The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?
Check the blood pressure.
Obtain emergency help.
Bring a glucometer to the room
Feel for a carotid pulse.
The Correct Answer is B
A. Check the blood pressure: Assessing blood pressure is not the immediate priority when a client is found unresponsive. Vital signs should be taken after confirming the client’s responsiveness, pulse, and breathing, and after activating emergency help if necessary.
B. Obtain emergency help: The first and most critical action is to call for emergency assistance to initiate the facility’s emergency response system. Immediate help ensures that advanced life support measures and resuscitation equipment can be provided without delay.
C. Bring a glucometer to the room: Checking blood glucose is important if hypoglycemia is suspected, but it should only be done after confirming airway, breathing, and circulation. Delaying emergency activation while obtaining equipment may waste resuscitation time.
D. Feel for a carotid pulse: Assessing the carotid pulse is part of the initial assessment sequence but should occur simultaneously or immediately after emergency help is called. The PN should ensure help is on the way before beginning pulse or breathing checks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prioritizing the current procedure ensures patient safety, as measuring residual volume is necessary to prevent complications like aspiration. Having the UAP communicate a brief delay maintains timely pain management while keeping the ongoing procedure safe.
B. Delegating the feeding to the UAP is inappropriate because measuring residual volume is a nursing responsibility requiring clinical judgment. Transferring this task could risk incorrect feeding and compromise client safety.
C. Minimizing a client’s pain is unsafe and dismissive. Pain requires timely assessment and intervention, and instructing the UAP to ignore the request could violate standards of care and ethical practice.
D. Residual volume measurement involves assessment and clinical judgment and cannot be delegated to the UAP. Allowing the UAP to perform it could result in inaccurate measurements or unsafe care.
Correct Answer is D
Explanation
A. Consensual pupillary constriction present: Consensual response refers to both pupils constricting simultaneously when light is shone in one eye. This finding assesses cranial nerves II and III but does not describe the pupillary adjustment to near and far focus.
B. Peripheral vision intact: Peripheral vision tests the client’s ability to detect objects in the visual fields and is unrelated to pupillary movement or accommodation. It does not involve observing pupil constriction during focus changes.
C. Nystagmus present with pupillary focus: Nystagmus involves involuntary, rhythmic eye movements typically associated with vestibular or neurological disorders. It does not describe normal pupillary constriction when shifting focus between distances.
D. Pupils reactive to accommodation: When pupils constrict as the eyes focus from a distant to a near object, it indicates a normal accommodation response. This finding reflects proper functioning of cranial nerve III and normal ocular motor coordination.
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