A client was found unconscious in a burning wooden shed and is admitted to the intensive care unit. The client is tachypneic and restless, with a respiratory rate of 32 breaths/min. The client's oxygen saturation is 99%
The most appropriate action by the nurse is to a. administer morphine for both pain and anxiety control.
b. apply oxygen at 2 L by nasal cannula.
c. check the oximeter to see if it is working.
d. request the physician order a carboxyhemoglobin level.
D
Carbon monoxide (CO) is produced by incomplete combustion of organic substances (e.g., wood or coal). It has an affinity for hemoglobin that is 200 times that of oxygen and will preferentially bind with hemoglobin when present. The result is tissue hypoxia. This client has a high risk for exposure to CO and is exhibiting signs of hypoxia. The nurse should request the physician order a carboxyhemoglobin level. If asphyxiation with CO is suspected, oxygen needs to be administered at 100% via a non-rebreathing facemask. Pulse oximetry will be unreliable in cases of CO poisoning.
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The discharge process is completed when the nurse: Standard Text: Select all that apply
1. Closes the door on the client's transportation vehicle 2. Report that the discharge is complete is given to the nurse manager 3. Client's reaction to discharge is recorded on the client's medical record 4. Discharge time, transportation and who accompanied client are recorded in the client's medical record 5. Client signs the discharge instructions
During class, the student can usually take effective notes by all of the following except:
a. writing key words and phrases. b. drawing symbols and labeling. c. writing verbatim all that is said. d. underlining and highlighting.
Prior to being discharged, a client tells the nurse that he is optimistic that the prescribed treatment is going to work for his illness, and he hopes to celebrate another holiday season in a few months. This client is demonstrating:
1. Denial 2. Apprehension 3. Conflict 4. Spiritual strength
When admitting a woman of child-bearing age to the surgical nursing unit, the nurse should:
a. assess the client's use of oral contraceptives. b. provide preoperative teaching. c. ask the client's husband to leave the room during the admission process. d. compare the client's admission weight with a standardized chart.