A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first?

Rationale: A. Establish an IV access: Establishing IV access is important for administering emergency medications or fluids, but it is not the first priority. Ensuring that the client has a patent airway and effective circulation takes precedence over IV access in an unresponsive client. B. Apply a blood pressure cuff: Measuring blood pressure provides valuable information about the client’s hemodynamic status, but it is secondary to assessing circulation. Immediate assessment of pulse and airway is needed to determine if life-saving interventions, such as CPR, are required. C. Initiate cardiac monitoring for the client: Cardiac monitoring helps detect arrhythmias and guides treatment, but it does not replace the initial assessment of vital signs and circulation. Monitoring is initiated after airway, breathing, and pulse assessment are secured. D. Palpate for the client's carotid pulse: Assessing the carotid pulse is the first action because it rapidly determines the presence of circulation in an unresponsive client. Immediate pulse assessment guides subsequent interventions, including initiating CPR if the pulse is absent, making it the priority according to the airway-breathing-circulation (ABC) approach.