The nurse enters a client's room who is found on the ground. The nurse should perform which initial action?A. Assess the client’s level of consciousnessB. Examine the client for injuriesC. Call the rapid response team (RRT)D. Palpate the client’s carotid pulse
Question
The nurse enters a client's room who is found on the ground. The nurse should perform which initial action?A. Assess the client’s level of consciousnessB. Examine the client for injuriesC. Call the rapid response team (RRT)D. Palpate the client’s carotid pulse
Solution
The initial action the nurse should perform is A. Assess the client’s level of consciousness. This is the first step in the primary survey in patient assessment, which follows the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach. By assessing the level of consciousness, the nurse can determine if the patient's airway is clear and if they are responsive. This can also provide an initial indication of the patient's brain function. After this, the nurse can proceed with the other options like examining for injuries, calling the rapid response team if necessary, and palpating the carotid pulse.
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