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?
Feel for a carotid pulse.
Bring a glucometer to the room.
Check the blood pressure.
Obtain emergency help.
The Correct Answer is D
A. Feel for a carotid pulse: Assessing for a carotid pulse is part of the initial CPR sequence, but it should not delay activating emergency assistance. The PN should first ensure help is on the way before further assessment steps are performed.
B. Bring a glucometer to the room: Checking blood glucose is appropriate only after confirming that the client has a pulse and is breathing. In an unresponsive client, the immediate priority is to secure emergency assistance and begin basic life support if indicated.
C. Check the blood pressure: Measuring blood pressure is not the first priority when a client is found unresponsive. Rapid assessment of responsiveness, breathing, and pulse should occur after calling for help, not detailed vital sign measurements.
D. Obtain emergency help: Activating the emergency response system ensures immediate support from the resuscitation team or emergency services. This is the first and most critical step when a client is found unresponsive to initiate timely life-saving interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using a tight seal around the mouthpiece: Maintaining a tight seal ensures accurate measurement of inspired air volume and prevents air leakage. This is an appropriate action that promotes lung expansion and prevents postoperative atelectasis.
B. Sitting upright during the treatment: The upright position allows maximum lung expansion and optimal diaphragmatic movement. This position enhances the effectiveness of deep breathing exercises using the incentive spirometer.
C. Blowing forcefully into the mouthpiece: The client should inhale slowly and deeply through the mouthpiece, not blow into it. Forcefully exhaling indicates misuse of the device, as the purpose is to encourage sustained inspiration to expand the alveoli and improve ventilation.
D. Exhaling slowly after two seconds: Slow exhalation after holding the breath allows gradual air release and helps maintain alveolar inflation. This step supports proper technique following the deep inhalation performed during incentive spirometry.
Correct Answer is ["B","C","E"]
Explanation
A. Three mL syringe: A syringe is typically used to flush or access a saline lock, not for removal. It is not required for the removal procedure itself.
B. Paper tape: Tape may be needed to secure a gauze pad over the site after removal to maintain pressure and prevent bleeding. This is an appropriate supply to gather.
C. Exam gloves: Nonsterile exam gloves protect the nurse and maintain basic hygiene while removing the saline lock. They are appropriate for this procedure.
D. Sterile gloves: Sterile gloves are not necessary for removing a saline lock, as the procedure does not involve entering a sterile body cavity. Standard precautions with clean gloves are sufficient.
E. Small gauze pad: A gauze pad is needed to apply pressure to the insertion site after removing the saline lock to prevent bleeding and promote hemostasis.
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