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 A
Explanation
- A: A heart rate greater than 60/min indicates that the transcutaneous pacing is effectively maintaining a heart rate within a normal range, which is crucial for adequate cardiac output and systemic perfusion.
- B: While 2+ pedal pulses indicate good peripheral perfusion, they do not directly reflect the effectiveness of transcutaneous pacing in treating complete heart block.
- C: Pacer spikes should appear before the QRS complex to show that the pacing stimulus is being delivered appropriately. Spikes after the QRS complex suggest that the pacing is not capturing the heart effectively.
- D: Distended jugular veins would be more indicative of heart failure or fluid overload and do not directly relate to the effectiveness of pacing therapy.
Correct Answer is A
Explanation
A.
A. Visible contusions on all four extremities may indicate physical abuse, especially in the context of being brought to the emergency department by a family member. Reporting the
incident to Adult Protective Services is essential to ensure the safety and well-being of the client.
B. Interviewing the client with his adult child present may not be appropriate if there are concerns about potential abuse or coercion.
C. Forcing the client to answer every assessment question may not be appropriate if the client is in distress or unable to communicate freely.
D. Advising the client to consult a social worker may be appropriate, but reporting suspected abuse to Adult Protective Services is the priority action in this situation.
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