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.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.
B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can
introduce the risk of infection, which is particularly concerning in clients with neutropenia.
C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.
D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.
Correct Answer is D
Explanation
A. Administer an antitoxin: There is no specific antitoxin available for anthrax. Treatment primarily involves antibiotics and supportive care.
B. Quarantine the client: Quarantine may not be necessary unless the client is confirmed to have an active infection or poses a risk of spreading the disease to others.
C. Monitor the client for a productive cough: While respiratory symptoms can occur in inhalation anthrax, monitoring for a productive cough alone may not be sufficient for management.
D. Begin prophylactic treatment with ciprofloxacin: Prophylactic antibiotic treatment with ciprofloxacin or doxycycline is recommended following exposure to anthrax to prevent the development of the disease.
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