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 D

Explanation

A. A client who has a fractured fibula and tibia: This is incorrect. While serious, this injury does not require immediate life-saving intervention and is generally categorized as less urgent.
B. A client who has sustained a major burn to their upper torso and extremities: This is incorrect. Although severe, if the client is stable and responsive, they may be categorized as yellow (delayed) unless there are immediate life-threatening complications.
C. A client who has a sprained ankle and laceration to the lower leg: This is incorrect. These injuries are considered less severe and would typically be tagged as green (minor).
D. A client who has an open traumatic brain injury and agonal breaths: This is correct. Agonal breaths and severe head injury indicate a need for immediate life-saving intervention, so this client should receive a red tag for the highest priority.

A. Remove the dressing to inspect the wound. B. Prepare to insert a central line. C. Raise the foot of the bed to a 90° angle. D. Administer oxygen via nasal cannula.

Correct Answer is D

Explanation

A. Remove the dressing to inspect the wound: This could exacerbate the wound and increase the risk of air entering the pleural space. The priority is to manage the wound to prevent further complications.
B. Prepare to insert a central line: While a central line might be needed for severe fluid resuscitation or medication administration, addressing the immediate airway and breathing concerns is more urgent.
C. Raise the foot of the bed to a 90° angle: This position is not appropriate for managing a sucking chest wound and does not address the immediate respiratory needs.
D. Administer oxygen via nasal cannula: The client is showing signs of hypoxia and increased respiratory distress. Administering oxygen will help improve oxygenation and manage symptoms of hypoxia until further interventions can be taken.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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?

Correct Answer is D

Explanation

A nurse is assessing a client who is being admitted from the post-anesthesia care unit (PACU) following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?

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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?

A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?

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 working in an emergency department is caring for a client who has third-degree frostbite to both lower extremities. The nurse should take which of the following actions?

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

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