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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Increased sweating: This is incorrect. Increased sweating is not typically indicative of internal hemorrhaging. It can be associated with various conditions but is not a specific sign of internal bleeding.
B. Increased redness at the site: This is incorrect. Increased redness would more likely be associated with localized infection or inflammation rather than internal hemorrhaging.
C. Increased abdominal distention: This is correct. Increased abdominal distention can be a sign of internal hemorrhaging, particularly if blood accumulates in the abdominal cavity (hemoperitoneum), leading to abdominal swelling and discomfort.
D. Increased blood pressure: This is incorrect. Internal hemorrhaging often leads to hypotension rather than increased blood pressure, as blood volume decreases and the body attempts to compensate.

A. Administer pain medication. B. Administer antibiotic therapy. C. Administer an antiviral medication. D. Administer an antitoxin.

Correct Answer is B

Explanation

A. Administer pain medication: Pain management is not the primary intervention for exposure to anthrax; the focus should be on addressing the disease directly.
B. Administer antibiotic therapy: This is correct. Post-exposure prophylaxis with antibiotics is crucial in preventing the development of anthrax, especially after exposure to spores.
C. Administer an antiviral medication: This is incorrect. Anthrax is caused by bacteria, not viruses, so antiviral medications are not effective.
D. Administer an antitoxin: While antitoxins are used in treating symptomatic anthrax, the immediate and appropriate action for exposure is to start antibiotic therapy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with multiple injuries to the head, chest, and abdomen has had their airway stabilized and is breathing on their own. Which symptom would lead the nurse to suspect internal hemorrhaging even when the nurse does not see any bleeding?

Correct Answer is C

Explanation

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the most appropriate action for the nurse to take?

Correct Answer is B

Explanation

A nurse is educating a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client requires further education?

A nurse in an emergency department is caring for a client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?

A nurse is caring for a client who has just received the diagnosis of endometrial cancer. During the nursing assessment, which of the following manifestations is likely to be reported by this client?

A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?

A nurse is performing triage on the incident scene for several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?

The nurse is teaching a class on bioterrorism. Which statement by a student indicates understanding of the primary rationale for designating an area for decontamination?

A nurse is presenting educational materials to a group of middle-aged clients about menopausal hormone therapy following total hysterectomy. Which of the following information should the nurse include in the education?