Question

A 35-year old man is brought to the emergency department by EMS personnel after he was found sitting in the car in an enclosed garage with the motor running. He is unresponsive and hypotensive, and his skin is bright red. Which intervention would have the greatest priority?A. Administration of oxygen B. Placing the client in a prone position. C. Administration of Narcan D. Initiating CPR.

Short answer

The priority intervention for a suspected carbon monoxide poisoning case is the administration of oxygen (A).

Step-by-step solution

Identify the Key Features of the Scenario

The scenario presents a 35-year old man found unresponsive in a closed garage with the engine running, hypotension, and bright red skin. These features are indicative of carbon monoxide poisoning.

Recognize the Most Immediate Threat

The greatest threat to the patient's life in the scenario of suspected carbon monoxide poisoning is the lack of oxygen in the blood, which can lead to tissue hypoxia and life-threatening complications.

Choose the Appropriate First Intervention

The priority intervention for carbon monoxide poisoning is the Administration of 100% oxygen, which helps to displace carbon monoxide from hemoglobin, thereby increasing the oxygen content in the blood.

Key concepts

NCLEX-RN Examination

The NCLEX-RN (National Council Licensure Examination for Registered Nurses) is a standardized exam that all nursing graduates must pass to become licensed to practice nursing in the United States. It assesses the knowledge, skills, and abilities that are essential for safe and effective practice as an entry-level nurse.

The exam is divided into four major categories: Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. In the given scenario, test-takers must employ clinical reasoning to determine the most immediate and effective intervention for a patient with suspected carbon monoxide poisoning. The question is designed to assess the nurse's ability to prioritize care based on the patient's condition and the severity of symptoms.

Emergency Nursing Care

Emergency nursing care involves the initial assessment and management of patients presenting with acute conditions, trauma, or exacerbations of chronic illnesses. It requires rapid clinical evaluation and immediate intervention to prevent further deterioration.

In our scenario, the patient shows signs of carbon monoxide poisoning—an acute emergency necessitating prompt nursing intervention. Key steps in emergency care for this patient include ensuring airway patency, breathing, and circulation (the ABCs) and immediately administering treatments to reverse the effects of the poisoning. These steps underscore the nurse's role in recognizing life-threatening conditions and initiating lifesaving care.

Oxygen Therapy

Oxygen therapy is the administration of oxygen as a medical intervention to maintain adequate tissue oxygenation. In cases of carbon monoxide poisoning, the affinity of carbon monoxide for hemoglobin is approximately 240 times stronger than that of oxygen. This means that without intervention, oxygen cannot effectively displace carbon monoxide from hemoglobin.

The administration of 100% oxygen via a non-rebreather mask or hyperbaric oxygen in severe cases can rapidly lower the level of carboxyhemoglobin in the blood, thereby alleviating hypoxia. Timely oxygen therapy is crucial in preventing organ damage and potentially fatal outcomes.

Clinical Reasoning

Clinical reasoning is the process by which nurses and other healthcare providers collect clues, process the information, understand the patient's health problem, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process.

Strong clinical reasoning skills would lead the nurse to prioritize the administration of oxygen (Option A) for the patient in our scenario. This decision is based on identifying the classic presentation of carbon monoxide poisoning and understanding that reversing hypoxia is the immediate priority. Nursing interventions must be based on a solid foundation of clinical knowledge and prioritization of care.