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 B

Explanation

A. History of sexually transmitted infection (STI): This is incorrect. A history of STI is not a contraindication for menopausal hormone therapy.
B. History of breast cancer: This is correct. Hormone therapy is not recommended for individuals with a history of breast cancer due to the potential risk of cancer recurrence or progression.
C. History of chronic obstructive pulmonary disease (COPD): This is incorrect. While HT might not be the primary treatment for COPD, it is not contraindicated solely due to COPD.
D. History of thyroiditis: This is incorrect. A history of thyroiditis does not contraindicate the use of hormone therapy for menopause.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

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 presenting educational materials to a group of middle-aged clients about menopausal hormone therapy following total hysterectomy. Which of the following information should the nurse include in the education?

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 is caring for a client who has just received the diagnosis of endometrial cancer. During the nursing assessment, which of the following manifestations is likely to be reported by this client?

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 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 in a healthcare provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil?

A nurse is discussing emergency response with a newly licensed nurse. Which statement by the newly licensed nurse indicates an understanding of who can serve as a triage officer during this time?