What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?
Assess breath sounds and respiratory efforts
Establish vascular access with a large-bore catheter
Remove clothing to perform a complete physical assessment
Evaluate level of consciousness (LOC) using the Glasgow Coma Sale (GCS)
The Correct Answer is A
A. In an unconscious patient, airway and breathing take priority according to the ABC (Airway, Breathing, Circulation) approach in emergency care. Even if the patient is breathing spontaneously, the nurse must assess for adequate oxygenation, airway patency, and signs of respiratory compromise before addressing other interventions. Immediate identification of airway obstruction or inadequate breathing can be life-saving.
B. Incorrect as the first action. While IV access is important for fluid resuscitation or medication administration, it does not take priority over ensuring airway and effective breathing, which are immediately life-sustaining.
C. Incorrect as the first action. A full physical assessment is important for identifying injuries, but airway and breathing must be addressed first. Removing clothing can occur after the patient is stabilized.
D. Incorrect as the first action. Assessing LOC is important to monitor neurological status, but it does not take priority over ensuring the patient can maintain adequate ventilation and oxygenation. LOC assessment can be done simultaneously or immediately after securing airway and breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. This value is slightly elevated but within a range that does not indicate immediate compromise. It may reflect anxiety or a mild stress response.
B. Tachycardia in this context suggests physiologic stress and compensatory responseto hypoxia, anxiety, or early respiratory compromise, requiring intervention and monitoring.
C. A respiratory rate above 20 with labored breathing indicates increased work of breathing and potential respiratory distress, which requires immediate nursing assessment and intervention.
D. This is a low-grade elevation and does not require immediate action in this context. It may reflect mild inflammation or recent activity, not an acute threat.
E. Oxygen saturation below 92% on supplemental oxygen indicates inadequate oxygenation, which requires prompt intervention such as assessing airway patency, suctioning secretions, adjusting oxygen delivery, or notifying the healthcare provider.
Correct Answer is D
Explanation
A. Polycythemia is an increased red blood cell countand is not associated with DIC. It does not reflect the coagulation abnormalitiesseen in disseminated intravascular coagulation.
B. Thrombocytosis is an elevated platelet count, whereas DIC is characterized by platelet consumption leading to thrombocytopenia, not an increase in platelets.
C. Bicarbonate levels are a marker of acid-base balance. In DIC, metabolic acidosis may occur secondary to tissue hypoxia, but bicarbonate itself is not a direct indicator of DIC.
D. DIC is a disorder of systemic coagulation activation, causing widespread clot formation and consumption of clotting factors, including fibrinogen. A low fibrinogen levelis a classic laboratory finding and suggests that the client is developing or has developed DIC. Other signs may include prolonged PT/PTT, thrombocytopenia, and increased D-dimer.
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