A young man is noticed 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
The immediate nursing diagnosis and action for this nurse is: 1. impaired gas exchange. Have the person lie down flat right where he is and begin rescue breathing. If the nurse sees anyone, call for help with CPR.
2. impaired gas exchange resulting from inhalation of carbon monoxide. Lead the patient away from the garage and call for help. Stay with the patient and continu-ally assess LOC and respirations.
3. impaired circulatory perfusion resulting from sulfur dioxide poisoning. Have the patient lie down flat, keep the patient still, and call for help.
4. impaired gas exchange. Have the man breathe deeply and continuously into a brown paper bag. Assess pulse, respirations, and color of conjunctiva. Check the man's pockets for a cell phone to call 911.
2
The man is still conscious enough to speak, although slowly, and therefore does not yet need CPR. Fumes from the garage are entering the air around them. There is a need to get the nurse and the man away from the fumes. The man may at any time lose consciousness; sit-ting down would prevent a fall, so the nurse should call for help. Staying reassures the pa-tient and lessens his or her anxiety response.
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