Question

The nurse is visiting an older adult client in the home for a dressing change. When the nurse arrives she finds the client on the floor, unresponsive. What is the priority action by the nurse?

Answer 1

The priority action for a nurse who finds an unresponsive patient is to assess the situation, call for emergency help, check for breathing and pulse, and begin CPR if necessary, following the basic life support (BLS) protocol.

Step-by-step explanation:

Priority Action for an Unresponsive Patient

When a nurse encounters an unresponsive older adult client on the floor, the priority action is to assess the client's responsiveness and call for emergency medical services (EMS). The nurse must ensure the safety of the environment, check for breathing and a pulse, and commence lifesaving interventions if necessary. According to the principles of emergency care, it's crucial to address any life-threatening issues first. The scenario resembles that in drowning incidents where the first priority is to bring the person to stable ground before beginning CPR. In this case, if the nurse finds that the client does not have a pulse and is not breathing, they should start CPR immediately after ensuring the environment is safe and calling for help. The protocol of surveying the scene for safety, calling for help, assessing breathing and pulse, and starting CPR is consistent with basic life support (BLS) procedures.