A client was found in a parked car with the motor running. The paramedic brought the client to the emergency department with complaints of a headache, nausea, and dizziness and the client is unable to recall their name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first?
Prepare the client for transfer to a facility with a hyperbaric chamber.
Apply oxygen via a nonrebreather mask at 15 liters.
Check the client's oxygenation level with a pulse oximeter.
Administer intravenous (IV) fluids.
The Correct Answer is B
A. Prepare the client for transfer to a facility with a hyperbaric chamber: This may be required for severe cases of carbon monoxide poisoning, but immediate intervention with high-flow oxygen is essential first.
B. Apply oxygen via a nonrebreather mask at 15 liters: Carbon monoxide poisoning requires immediate high-flow oxygen to help displace carbon monoxide from hemoglobin. This is the first step in treatment to prevent further tissue hypoxia and complications.
C. Check the client's oxygenation level with a pulse oximeter: While important, it does not address the immediate need for high-flow oxygen to treat carbon monoxide poisoning.
D. Administer intravenous (IV) fluids: IV fluids may be necessary for supportive care but are not the priority for treating carbon monoxide poisoning. The immediate need is to provide high-flow oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hemorrhage: This is the priority complication to monitor for in the immediate postoperative period after a transurethral resection of the prostate (TURP). Hemorrhage can lead to significant blood loss and requires prompt intervention.
B. Pain: While pain management is important, it is not the immediate priority compared to the risk of hemorrhage in the postoperative setting.
C. Urinary retention: Although important to monitor, urinary retention is a common postoperative issue but does not pose the same immediate risk as hemorrhage.
D. Infection: Infection is a concern but typically develops later in the postoperative period and is not as immediate a risk as hemorrhage.
Correct Answer is ["56"]
Explanation
To calculate the infusion rate, we'll use the following formula:
Infusion rate (gtt/min) = (Volume to be infused (mL) / Time (min)) Drop factor (gtt/mL)
First, calculate the total time in minutes:
- 3 hours 60 minutes/hour = 180 minutes
Then, calculate the volume per minute:
- 500 mL / 180 minutes = 2.78 mL/min
Finally, multiply the volume per minute by the drop factor:
- 2.78 mL/min 20 gtt/mL = 55.6 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 56 gtt/min.
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