A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?

Take the client outdoors.

Wrap blankets around the client.

Loosen the client's clothing.

Open the client's windows.

Answer and Explanation

The Correct Answer is A

A. The priority action is to remove the client from the source of carbon monoxide poisoning, which in this case is the kerosene space heater. Taking the client outdoors will provide fresh air and reduce exposure to carbon monoxide.

B. Wrapping blankets around the client may further exacerbate the symptoms by trapping the carbon monoxide, worsening the client's condition.

C. While loosening the client's clothing may improve ventilation, it is not as effective as removing the client from the source of exposure.

D. Opening the client's windows may help improve ventilation, but it is not as effective as taking the client outdoors to reduce exposure to carbon monoxide.

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Correct Answer is D

Explanation

A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.

B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.

C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.

D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.

A. An air leak noted at the insertion site. B. The tubing may be kinked. C. Water needs to be added to the suction-control chamber. D. The suction is set too low.

Correct Answer is B

Explanation

A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.

B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.

C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.

D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.

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A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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