HESI Registered Nurse EXIT Practice Exam

Upon finding a client lying still and silent on the floor, what should the nurse assess first?

1. Assess the client's airway

2. Call for help

3. Establish that the client is unresponsive

4. See if anyone saw the client fall

The correct answer is: Establish that the client is unresponsive

The first action for the nurse when finding a client lying still and silent on the floor is to establish if the client is unresponsive. This crucial step helps in determining the level of consciousness and whether the client requires immediate intervention. Confirming unresponsiveness allows the nurse to prioritize the subsequent steps in a safe and effective manner. When a client is found unresponsive, it is vital to assess for airway, breathing, and circulation — often summarized as the ABCs of emergency care. However, establishing unresponsiveness comes first, as it directly informs the urgency of those subsequent assessments and interventions. Other considerations, such as calling for help or checking if others witnessed the fall, are important but should follow the initial assessment of the client's responsiveness. Ensuring the client’s immediate needs are addressed is paramount, as any delay could impact their outcome.