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    Med surg 2 proctored examQuestion 62
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    Med surg 2 proctored exam

    What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?

    Explanation & Rationale

    A. In an unconscious patient, airway and breathing take priority according to the ABC (Airway, Breathing, Circulation) approach in emergency care. Even if the patient is breathing spontaneously, the nurse must assess for adequate oxygenation, airway patency, and signs of respiratory compromise before addressing other interventions. Immediate identification of airway obstruction or inadequate breathing can be life-saving. B. Incorrect as the first action. While IV access is important for fluid resuscitation or medication administration, it does not take priority over ensuring airway and effective breathing, which are immediately life-sustaining. C. Incorrect as the first action. A full physical assessment is important for identifying injuries, but airway and breathing must be addressed first. Removing clothing can occur after the patient is stabilized. D. Incorrect as the first action. Assessing LOC is important to monitor neurological status, but it does not take priority over ensuring the patient can maintain adequate ventilation and oxygenation. LOC assessment can be done simultaneously or immediately after securing airway and breathing.

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