Nokea
A child presents to the Emergency Department with documented acetaminophen poisoning. In order to provide counseling and education for the parents, which principle must the nurse understand?
- A. The problem occurs in stages with recovery within 12-24 hours
- B. Hepatic problems may occur and may be life-threatening
- C. Full and rapid recovery can be expected in most children
- D. This poisoning is usually fatal, as no antidote is available
Correct Answer: B
Rationale: Hepatic problems may occur and may be life-threatening. Clinical manifestations associated with acetaminophen poisoning occur in 4 stages. The third stage is hepatic involvement which may last up to 7 days and be permanent. Clients who do not die in the hepatic stage gradually recover.
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The client is admitted to the burn unit and prescribed pantoprazole (Protonix), a proton pump inhibitor (PPI). Which statement best supports the scientific rationale for administering this medication to a client with a severe burn?
- A. This medication will help prevent a stress ulcer.
- B. This medication will help prevent systemic infections.
- C. This medication will provide continuous vasoconstriction.
- D. This medication will stimulate new skin growth.
Correct Answer: A
Rationale: Severe burns increase stress ulcer risk due to gastric acid hypersecretion; PPIs like pantoprazole prevent this. Infection, vasoconstriction, or skin growth are unrelated.
A client newly diagnosed with Type I Diabetes Mellitus asks the purpose of the test measuring glycosylated hemoglobin. The nurse should explain that the purpose of this test is to determine:
- A. The presence of anemia often associated with Diabetes
- B. The oxygen carrying capacity of the client's red cells
- C. The average blood glucose for the past 2-3 months
- D. The client's risk for cardiac complications
Correct Answer: C
Rationale: The average blood glucose for the past 2-3 months. By testing the portion of the hemoglobin that absorbs glucose, it is possible to determine the average blood glucose over the life span of the red cell, 120 days.
An adult is receiving Gantrisin 1 g PO qid for a urinary tract infection. Which statement that she makes indicates a need for more teaching?
- A. If I get a rash, I will apply calamine lotion.
- B. I will take my pills with a full glass of water.
- C. I will take all the pills even if I feel better.
- D. I will stay out of the sun while I am taking the pills.
Correct Answer: A
Rationale: A rash may indicate an adverse reaction to Gantrisin, requiring physician consultation, not self-treatment with calamine lotion.
An adult is hospitalized for an acute attack of gout. Which medication should the nurse expect to administer?
- A. Morphine
- B. Colchicine
- C. Allopurinol
- D. Acetaminophen
Correct Answer: B
Rationale: Colchicine is used to treat acute gout attacks by reducing inflammation, unlike allopurinol, which prevents attacks.
A nurse is caring for a client who is receiving methyldopa hydrochloride (Aldomet) intravenously. Which of the following assessment findings would indicate to the nurse that the client may be having an adverse reaction to the medication?
- A. Headache
- B. Mood changes
- C. Hyperkalemia
- D. Palpitations
Correct Answer: B
Rationale: Mood changes. The nurse should assess the client for alterations in mental status such as mood changes. These symptoms should be reported promptly.