An 80-year-old woman is brought to the emergency department after being found unconscious in her garage sitting in her car. Which assessment finding is most concerning to the nurse?
a. Temperature, 97.6° F; pulse, 98; and blood pressure, 110/60
b. Oxygen (O2) saturation of 78%
c. Cherry red mucous membranes
d. Cold extremities
C
The cherry red mucous membranes are classic signs of carbon monoxide poisoning; unfortunately, they are very late signs. The temperature, pulse, and blood pressure are within normal limits. An O2 saturation of 78% could be corrected if accurate, and O2 saturation measurements are inaccurate in cases of carbon monoxide poisoning. Cold extremities do not necessarily indicate an urgent problem.
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Fill in the blank(s) with the appropriate word(s).