A Young Man Is Staggering Out of a Partially Closed

question 23

Multiple Choice

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.The immediate nursing diagnosis and action for this nurse is:

• A) The immediate nursing diagnosis is impaired gas exchange. Ask the person to lay flat right where he is; begin rescue breathing. If the nurse sees anyone else, he or she should ask the individual to call someone who knows CPR.
• B) The immediate nursing diagnosis is 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 LOC and respirations.
• C) The immediate nursing diagnosis is impaired circulatory perfusion resulting from sulfur dioxide poisoning. Have the patient lie flat. Keep the patient still, and call for help.
• D) The immediate nursing diagnosis is impaired gas exchange. Have the patient breathe deeply and continually into a brown paper bag. Assess pulse, respirations, and color of conjunctiva. Check the patient's pockets for a cell phone to call 9-1-1.

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Definitions:

Normal Distribution

A chance distribution evenly balanced around the mean, revealing that instances close to the mean occur more frequently than those far from it.

Standard Deviations

A measure of the dispersion or variability within a set of data, indicating how much individual data points differ from the mean.

Mean

The average value of a set of numbers, calculated by dividing the sum of the numbers by the count of the numbers.

Normal Curve

A symmetrical bell-shaped curve representing the distribution of values, traits, or characteristics that are normally distributed.