A young man is staggering out of a partially closed doorway to a garage, where a car is running inside. He speaks slowly in a very low voice, telling the nurse that he fell asleep in the car with the engine running

Question

What is the immediate nursing diagnosis and action? a. Impaired gas exchange. Ask the person to lie flat right where he is; begin rescue breathing. If the nurse sees anyone else, the nurse should ask the individual to call someone who knows CPR.
b. Impaired gas exchange resulting from the inhalation of carbon monoxide. Lead the patient away from the garage and call for help. Stay with the patient and continually assess level of consciousness and respira-tions.
c. Impaired circulatory perfusion resulting from sulfur dioxide poisoning. Have the patient lie flat. Keep the patient still and call for help.
d. Impaired gas exchange. Have the patient breathe deeply and continually into a brown paper bag. Assess pulse, respira-tions, and color of conjunctiva. Check the patient's pockets for a cell phone to call 9-1-1.

Answer 1

B
The man is still conscious enough to speak, but slowly, and therefore does not yet need CPR. Fumes from the garage are entering the air around them. Therefore, getting the nurse and the man away from the fumes is necessary. The man may, at any time, lose consciousness. Sitting down would prevent a fall; consequently, the nurse should call for help. Staying with the young man reassures him and lessens his anxiety response.