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.

Question

Quizplus · Accepted Answer

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.

A Client Was Found Unconscious in a Burning Wooden Shed