A client begins to hyperventilate after learning that a breast biopsy was positive for cancer. After a few minutes, the client loses consciousness. Which action by the nurse is the priority?

Question

A) Begin cardiopulmonary resuscitation.
B) Raise the side rails on the bed.
C) Notify the physician.
D) Insert an intravenous access device.

Answer 1

Answer: B

The nurse should protect the client from injury. If hyperventilation continues to the point where the client loses consciousness, respirations will return to normal, as will acid-base balance. The nurse should ensure for the client's safety and raise the side rails on the bed. The client does not need cardiopulmonary resuscitation. The physician may need to be notified; however, the client's safety is a priority. The client is not critically ill and an intravenous access device is not indicated at this time.