A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
a. Monitor the blood pressure.
b. Send the patient for a computed tomography (CT) scan.
c. Check the respiratory rate and effort.
d. Assess the Glasgow Coma Scale score.
ANS: C
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.
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