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. Massage the legs: This is incorrect. Massage is contraindicated as it can cause further tissue damage and is not appropriate for frostbite.
B. Apply dry heat to the legs: This is incorrect. Dry heat can exacerbate tissue damage. Rewarming should be done using controlled, warm water immersion, not dry heat.
C. Elevate the legs: This is correct. Elevating the legs helps reduce swelling and can prevent further tissue damage. However, rewarming should be done carefully in a controlled environment.
D. Immerse the legs in cold water: This is incorrect. Immersing in cold water would worsen the frostbite. Rewarming should be done using warm (not hot) water, ideally at 37-39°C (98.6-102.2°F), for effective treatment.

A. Manually irrigate the catheter. B. Check the catheter tubing for kinks. C. Notify the healthcare provider. D. Adjust the rate of the bladder irrigant.

Correct Answer is B

Explanation

A. Manually irrigate the catheter: This action is premature if the issue is due to a kink or obstruction in the tubing. Manual irrigation should only be performed if other less invasive measures do not resolve the issue.
B. Check the catheter tubing for kinks: This is the first step to take as kinks in the tubing can obstruct the flow of urine. Identifying and correcting kinks may resolve the problem without further intervention.
C. Notify the healthcare provider: This step may be necessary if other interventions do not resolve the issue, but it is not the first action.
D. Adjust the rate of the bladder irrigant: This may be relevant if the problem is related to the irrigation rate, but checking for kinks should be done first to ensure proper catheter function.

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Naxlex Comprehensive Predictor Exams

A nurse working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

Correct Answer is C

Explanation

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent?

A nurse is discussing emergency response with a newly licensed nurse. Which statement by the newly licensed nurse indicates an understanding of who can serve as a triage officer during this time?

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?

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 is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives?

A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?

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 working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take?