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. Initiate intravenous (IV) access for fluid replacement. This is important for managing shock or significant blood loss, but it is not the first priority in managing severe bleeding.
B. Place the client's arm in a dependent position. This would not be appropriate for severe bleeding and does not control hemorrhage effectively.
C. Apply pressure directly to the wound. This is correct. Direct pressure is the immediate and essential step to control bleeding in a severe wound. It helps to stabilize the clot and reduce blood loss.
D. Apply a tourniquet just below the level of the shoulder. This is not the first intervention. A tourniquet is used if direct pressure does not control severe bleeding and should be applied above the wound, not below.

A. Instruct the client to change clothing before arriving. B. Inform the client that photographs of any injuries will be mandatory for a police report. C. Ask the client to repeat the information obtained during admission. D. Obtain a history of the incident from the client.

Correct Answer is D

Explanation

A. Instruct the client to change clothing before arriving: This is incorrect. The client should be advised to keep the clothing they were wearing during the assault as evidence, not to change them.
B. Inform the client that photographs of any injuries will be mandatory for a police report: This is incorrect. While photographs might be necessary for evidence, it is not appropriate to make such statements without discussing consent and the client's comfort first.
C. Ask the client to repeat the information obtained during admission: This is incorrect. Repeating information may be distressing for the client. The nurse should obtain the history in a sensitive and supportive manner without unnecessary repetition.
D. Obtain a history of the incident from the client: This is correct. Gathering a detailed history is important for appropriate care and forensic evidence collection. The nurse should do this in a compassionate and nonjudgmental manner, ensuring the client feels supported.

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Correct Answer is C

Explanation

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?

Correct Answer is D

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 performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?

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 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 educating a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client requires further education?

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

A nurse is teaching a client who has benign prostatic hypertrophy and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching?