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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Pinch the testicles to feel for abnormalities: This is incorrect. The testicles should be gently palpated, not pinched, to detect abnormalities.
B. Expect swelling of the testicles after examination: This is incorrect. There should be no swelling after a testicular self-examination.
C. Perform testicular self-examination every year: This is incorrect. Self-examination should be performed monthly, not yearly, to detect any changes promptly.
D. Examine the testicles after a bath or shower: This is correct. The warmth and relaxation of the scrotum after a bath or shower make it easier to feel for abnormalities.

A. Allow a drinking glass on the client's meal tray. B. Place the client in four-point restraints. C. Inspect the client's personal belongings. D. Assign the client to a private room.

Correct Answer is C

Explanation

A. Allow a drinking glass on the client's meal tray: This is incorrect. Allowing objects that could potentially be used for self-harm is unsafe. All items on the client's meal tray should be carefully reviewed to ensure they do not pose a risk.
B. Place the client in four-point restraints: This is incorrect. Restraints are used as a last resort and should only be applied following a thorough assessment of the client's needs and risks, considering less restrictive measures first.
C. Inspect the client's personal belongings: This is correct. Inspecting personal belongings is crucial to ensure that the client does not have items that could be used for self-harm. This step helps in identifying and removing potential hazards.
D. Assign the client to a private room: This is incorrect. Assigning a client to a private room might not be appropriate as it could isolate the client and reduce opportunities for observation and intervention. A safer approach is to place the client in a room where they can be closely monitored, typically a shared room with staff supervision.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include?

Correct Answer is D

Explanation

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

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which postoperative complication is the priority for the nurse to monitor?

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 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?

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?

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 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 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 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?