Nokea
A child is admitted to the emergency room following ingestion of a bottle of Children's Tylenol. The nurse is aware that Tylenol poisoning is treated with:
- A. Acetylcysteine
- B. Deferoximine
- C. Edetate calcium disodium
- D. Activated charcoal
Correct Answer: A
Rationale: Acetylcysteine is the antidote for acetaminophen (Tylenol) overdose, protecting the liver from toxicity.
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The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
The nurse is caring for a client with bipolar disorder. The client has been manipulating some of the staff and other clients in order to get her way. Which actions by the nurse are appropriate in managing this client? Select all that apply.
- A. giving support when the client exhibits positive behaviors
- B. setting clear limits and communicating expected behaviors
- C. role playing with the client to demonstrate appropriate behaviors
- D. treating the client more like a friend in order to show respect for her as a person
- E. giving the client small gifts, such as extra dessert, in order to encourage appropriate behavior
Correct Answer: A,B,C
Rationale: Appropriate actions include reinforcing positive behaviors (A), setting clear limits (B), and role-playing (C) to promote appropriate interactions. Treating as a friend (D) or giving gifts (E) blurs boundaries and encourages manipulation.
The nurse receives an order to administer 1,500 mL D5W IV over 12 hours. The drop factor is 15 drops/1 mL. The IV flow rate should be set at how many drops per minute? Round to the nearest whole number.
Correct Answer: 31
Rationale: Flow rate (drops/min) = (volume × drop factor) ÷ time. Calculation: (1,500 mL × 15 drops/mL) ÷ (12 × 60) = 22,500 ÷ 720 ≈ 31 drops/min.
Which laboratory test is used to identify injury to the myocardium and can remain elevated for up to 3 weeks?
- A. Total CK
- B. CK-MB
- C. Myoglobin
- D. Troponin T or I
Correct Answer: D
Rationale: Troponin T or I is highly specific for myocardial injury and can remain elevated for up to 2-3 weeks, making it the best marker for detecting cardiac damage.
An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?
- A. .45 normal saline
- B. Dextrose 1% in water
- C. Lactated Ringer's
- D. Dextrose 5% in .45 normal saline
Correct Answer: C
Rationale: Lactated Ringer's is isotonic and effective for correcting dehydration in obstetric clients, replacing fluids and electrolytes.