NCLEX Practice Question (Answer 319)

 

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client?

1. Coma
2. Flushing
3. Dizziness
4. Tachycardia
 
Rationale

Answer and Rationale: 

 

Option 2 is Correct answer.

Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache,
decreased visual acuity, decreased cerebral functioning, and slight
breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus,
vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia;
levels of 41% to 60% result in seizure and coma; and levels higher than 60%
result in death.

 

Test-Taking
Strategy
: Use the process of elimination and focus
on the carbon monoxide level presented in the question. Remember that flushing
occurs with levels between 11% and 20%; this will assist you in answering
questions similar to this one. If you had difficulty with this question, review
the effects of an inhalation injury, carbon monoxide levels, and the associated
clinical manifestations.

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