The emergency department (ED) staff has been notified of the imminent arrival of a client who has experienced respiratory exposure to the chemical agent chlorine. Which finding should the anticipate with this exposure?

Decreased cardiac output

Hypovolemia

Chronic pain

Pulmonary edema

Answer and Explanation

The Correct Answer is D

A. Decreased cardiac output is not a primary concern with chlorine exposure, which primarily affects the respiratory system.
B. Hypovolemia is not directly related to chlorine gas exposure. The primary concern is respiratory damage.
C. Chronic pain is not an immediate or primary finding in chlorine gas exposure; the focus is on acute respiratory effects.
D. Pulmonary edema is a common and severe consequence of chlorine gas inhalation due to the corrosive effect of chlorine on the respiratory tract, leading to fluid accumulation in the lungs.

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Correct Answer is D

Explanation

A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.

A. Assess client for upper extremity injuries B. Suction saliva from the client's mouth C. Monitor the client's electrolyte levels D. Record the client's intake and output

Correct Answer is B

Explanation

A. Assessing for upper extremity injuries is important, but it is not the highest priority in an unconscious client who is at risk for airway obstruction.
B. Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
C. Monitoring electrolyte levels is important in the overall management of a client with cerebral hemorrhage, but it is not the immediate priority compared to securing the airway.
D. Recording intake and output is necessary for fluid balance monitoring but is secondary to the immediate need to maintain a patent airway in an unconscious client.

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The emergency department (ED) staff has been notified of the imminent arrival of a client who has experienced respiratory exposure to the chemical agent chlorine. Which finding should the anticipate with this exposure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?

Correct Answer is D

Explanation

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

Correct Answer is B

Explanation

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