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The nurse cares for a client in the emergency department. The client's friends state the client inhaled varnish remover and passed out. The nurse notices a rash around the client's nose and mouth, axillary temperature 97.8 degrees, pulse 66, respiration 12, blood pressure 168/88, and pulse oximetry 98%.

Which action should the nurse take FIRST?

A. Provide oxygen 2L per nasal cannula.
B. Evaluate pupillary response.
C. Listen to heart sounds.
D. Place patient in supine position.

Answer :

Final answer:

The nurse should first evaluate the patient's pupillary response to assess neurological function and consciousness level in the emergency department.

Explanation:

In cases like this where the client has inhaled varnish remover, a substance known to be toxic, and has become unconscious, the first assessment priority should be airway and breathing, as these are key to maintaining life. The nurse notes a rash around the client's nose and mouth which may indicate irritation or damage to the respiratory system. The nurse should first evaluate pupillary response to assess neurological function and consciousness before proceeding to the other tasks. This is very important in emergency department cases as it gives a quick insight into whether the brain has been deprived of oxygen, which can occur quickly following inhalation of a toxic substance.

Learn more about Emergency Department Nursing Care here:

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