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.
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Related Questions
Correct Answer is C
Explanation
A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.
B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.
C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.
D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.
Correct Answer is D
Explanation
A. Irregular uterine contractions at 38 weeks of gestation may not be a concern unless they become regular and more intense.
B. A client scheduled for a nonstress test (NST) at 39 weeks of gestation can typically wait until after attending to more urgent matters.
C. A client scheduled for an induction of labor at 40 weeks of gestation is not necessarily a priority unless there are urgent concerns.
D. Decreased fetal movement, especially for 2 days at 36 weeks of gestation, requires immediate assessment to ensure fetal well-being.
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