Nokea
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45
minutes ago is rushed to the emergency department. Which of these orders should the
nurse do first?
- A. Gastric lavage
- B. Administer acetylcysteine (Mucomyst) orally
- C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
- D. Have the patient drink activated charcoal mixed with water
Correct Answer: A
Rationale: Acetaminophen overdose is extremely toxic to the liver causing
hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting,
abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs
and may lead to death. Removing as much of the drug as possible is the first step in
treatment for acetaminophen overdose, this is best done through gastric lavage.
Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids
and then aspirating the fluid back out. This procedure is done in life-threatening
cases such as acetaminophen toxicity and only if less than one (1) hour has
occurred after ingestion.
You may also like to solve these questions
A systolic blood pressure of 145 mm Hg is classified as:
- A. Normotensive
- B. Prehypertension
- C. Stage I hypertension
- D. Stage II hypertension
Correct Answer: C
Rationale: A systolic blood pressure of 145 mm Hg falls within the range of 140-159 mm Hg, which is classified as Stage I hypertension. Normotensive individuals have a systolic blood pressure less than 120 mm Hg, making choice A incorrect. Prehypertension is characterized by a systolic blood pressure ranging from 120-139 mm Hg, excluding choice B. Stage II hypertension is diagnosed when the systolic blood pressure is greater than 160 mm Hg, making choice D incorrect. Therefore, the correct classification for a systolic blood pressure of 145 mm Hg is Stage I hypertension.
A patient diagnosed with alopecia would be described as having:
- A. body lice
- B. lack of ear lobes
- C. Indigestion
- D. hair loss
Correct Answer: D
Rationale: The correct answer is 'hair loss.' Alopecia is a medical term that specifically refers to the condition of hair loss, usually in patches or all over the body. Choice A, 'body lice,' refers to a parasitic infestation and is not related to alopecia. Choice B, 'lack of ear lobes,' is completely unrelated to the term alopecia, which is solely about hair loss. Choice C, 'Indigestion,' has no connection to alopecia as it pertains to digestive issues, not hair loss. Therefore, the correct description for a patient diagnosed with alopecia is 'hair loss.'
The nurse is caring for a 10-year-old upon admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct Answer: A
Rationale: The correct answer is urinary output of 30 ml per hour. In a 10-year-old child, this level of urinary output is indicative of adequate fluid replacement without suggesting overload. Monitoring urinary output is crucial in assessing fluid balance. Choices B, C, and D are incorrect. No complaints of thirst do not provide a direct assessment of fluid status. Increased hematocrit is a sign of dehydration, not adequate fluid replacement. Good skin turgor around the burn is a general assessment but may not directly reflect the child's overall fluid status.
A patient is being visited at home by a healthcare professional. The patient has been taking Naproxen for back pain. Which statement made by the patient most indicates that the healthcare professional needs to contact the physician?
- A. I get an upset stomach if I don't take Naproxen with my meals.
- B. My back pain right now is about a 3/10.
- C. I get occasional headaches since taking Naproxen
- D. I have ringing in my ears.
Correct Answer: D
Rationale: The correct answer is 'I have ringing in my ears.' Ringing in the ears is a severe adverse effect of Naproxen, indicating potential toxicity. This symptom warrants immediate medical attention. Choices A, B, and C are less concerning and do not directly indicate a severe adverse effect or toxicity related to Naproxen. Upset stomach, mild back pain, and occasional headaches are common side effects that may not require immediate physician contact.
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening
- B. Perform tests for sexually transmitted diseases
- C. Discuss her high risk for cervical cancer
- D. Refer the client to a family planning clinic
Correct Answer: A
Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step in identifying and managing the risk of HIV infection. Early detection allows for timely interventions and better outcomes. While performing tests for sexually transmitted diseases (choice B) is important, addressing the immediate and potentially life-threatening risk of HIV takes precedence. Discussing the risk for cervical cancer (choice C) is not the priority at this time as HIV screening is more urgent. Referring the client to a family planning clinic (choice D) is not the immediate priority given the client's current high-risk behavior and the need to address the immediate threat of HIV infection.