A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

A high concentration of carbon monoxide can cause death.

I should purchase a carbon monoxide detector for my home.

Breathing in carbon monoxide can cause headaches and nausea.

I can detect the presence of carbon monoxide by a metallic odor.

Answer and Explanation

The Correct Answer is D

Choice A reason: A High Concentration of Carbon Monoxide Can Cause Death

This statement is correct. Carbon monoxide (CO) is a colorless, odorless, and tasteless gas that can be deadly at high concentrations. It binds to hemoglobin in the blood more effectively than oxygen, leading to hypoxia (lack of oxygen) in body tissues. High levels of CO can cause severe symptoms such as confusion, loss of consciousness, and death if not treated promptly.

Choice B reason: I Should Purchase a Carbon Monoxide Detector for My Home

This statement is also correct. Installing a carbon monoxide detector in the home is a crucial safety measure. These detectors can alert individuals to the presence of CO, allowing them to take action before the gas reaches dangerous levels. It is recommended to place detectors near sleeping areas and to test them regularly to ensure they are functioning properly.

Choice C reason: Breathing in Carbon Monoxide Can Cause Headaches and Nausea

This statement is accurate. Early symptoms of carbon monoxide poisoning include headaches, dizziness, nausea, and fatigue. These symptoms occur because CO interferes with the body’s ability to transport and use oxygen, leading to hypoxia. If exposure continues, symptoms can worsen and lead to more severe health issues.

Choice D reason: I Can Detect the Presence of Carbon Monoxide by a Metallic Odor

This statement indicates a need for further instruction. Carbon monoxide is odorless, which means it cannot be detected by smell. This is why CO is often referred to as a “silent killer.” Relying on the ability to smell CO is dangerous and ineffective. The only reliable way to detect CO is through the use of a carbon monoxide detector.

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Correct Answer is D

Explanation

Choice A reason:

Administer 50,000 units of heparin by IV bolus every 12 hours: This dosage is incorrect and potentially dangerous. Heparin dosing must be carefully calculated based on the patient’s weight and coagulation test results. Standard practice involves adjusting the dose according to the aPTT levels to maintain therapeutic anticoagulation.

Choice B reason:

Have vitamin K available on the nursing unit: Vitamin K is the antidote for warfarin, not heparin. The antidote for heparin is protamine sulfate. Having the correct antidote available is crucial for managing potential bleeding complications associated with heparin therapy.

Choice C reason:

Use tubing specific for heparin sodium when administering the infusion: While it is important to use appropriate tubing for any IV medication, there is no specific tubing required exclusively for heparin sodium. Standard IV tubing is typically sufficient.

Choice D reason:

Check the activated partial thromboplastin time (aPTT) every 6 hours: This is correct. Monitoring aPTT levels is essential when administering a continuous heparin infusion. The aPTT test measures the time it takes for blood to clot and helps ensure that the heparin dose is within the therapeutic range. Regular monitoring helps prevent both under- and over-anticoagulation, reducing the risk of clotting or bleeding complications.

Correct Answer is []

Explanation

In this scenario, the client is most likely experiencing iron deficiency anemia, based on the diagnostic results that show low hemoglobin (10 mg/dL), low hematocrit (31%), and low serum ferritin (9 mcg/L), which are below the normal ranges for a pregnant individual.

The correct answers are:

Potential Condition:

a. Iron deficiency anemia

Actions to Take:

a. Administer iron supplements (to address the anemia and increase iron levels)
b. Teach the client about a diet rich in iron (to support iron supplementation and improve dietary intake of iron)

Parameters to Monitor:

a. Hemoglobin levels (to assess improvements in oxygen-carrying capacity and monitor for anemia)
b. Hematocrit levels (to monitor the volume of red blood cells and further assess anemia)

By addressing the low iron levels, administering supplements, and providing dietary guidance, the nurse can help correct the anemia. Monitoring hemoglobin and hematocrit will help track the client’s progress in overcoming the condition.

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A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

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