The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first?
A) Check for a carotid pulse.
B) Apply supplemental oxygen.
C) Give two full breaths.
D) Gently shake and shout, "Are you OK?"
Ans: D
Feedback:
Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.
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