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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. A client who has acute tonsillitis, is drooling, and has difficulty swallowing: This client is likely experiencing severe swelling or an airway obstruction, which requires immediate attention to ensure the airway is not compromised.
B. A client who sustained a deep laceration to their leg and is complaining of dizziness and weakness: While this client has concerning symptoms, airway compromise is prioritized in triage.
C. A client who has chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 88%: This client is hypoxic and requires prompt intervention, but airway issues take precedence.
D. A client who has lower left abdominal pain and bloody stools: This client may have a serious condition but does not require as immediate intervention as a compromised airway.

A. Increased vaginal drainage typically occurs 5 days following surgery. B. Sexual intercourse may be resumed in 1 to 2 weeks. C. Artificial lubrication can be used to treat vaginal itching and dryness. D. A Papanicolaou (Pap) test should be performed every 6 months.

Correct Answer is C

Explanation

A. Increased vaginal drainage typically occurs 5 days following surgery: This is incorrect. Vaginal drainage usually decreases over time after surgery, and increased drainage might suggest a complication.
B. Sexual intercourse may be resumed in 1 to 2 weeks: This is incorrect. Sexual activity is generally advised against for 6 weeks or until the healthcare provider confirms it is safe to resume.
C. Artificial lubrication can be used to treat vaginal itching and dryness: This is correct. After a hysterectomy and oophorectomy, vaginal dryness is common due to decreased estrogen levels. Artificial lubrication can help alleviate these symptoms.
D. A Papanicolaou (Pap) test should be performed every 6 months: This is incorrect. After a total abdominal hysterectomy for cancer, Pap tests are generally not required unless there was a history of cervical cancer or other specific indications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the healthcare provider to care for first?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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?

A client has been diagnosed with polycystic ovarian syndrome (PCOS). The nurse should encourage what health promotion activity to address the client's hormone imbalance and infertility?

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 110/60 mm Hg, a pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

A nurse is caring for a client who has been suspected of recent exposure to anthrax by inhalation. Which of the following findings would indicate the client has been exposed?

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?

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

Following a history of vaginal discharge and lower abdominal pain, a client is diagnosed with pelvic inflammatory disease (PID). When providing client education, the nurse identifies an understanding of the teaching when the client makes which statement in regard to preventing a reoccurrence?

A nurse is preparing to perform a Papanicolaou (Pap) test for a 35-year-old female client during a routine gynecological examination. Which of the following nursing interventions is most appropriate before conducting the procedure?