Nokea
A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?
- A. activated charcoal per pharmacy
- B. start an IV with D5W to keep the vein open
- C. gastric lavage PRN
- D. acetylcysteine (Mucomyst) for age per pharmacy
Correct Answer: A
Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.
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The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling her legs
- C. Have the client breathe deeply
- D. Provide the client additional fluids
Correct Answer: B
Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused. Which of the following responses by the nurse is MOST appropriate?
- A. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- B. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- C. Ignore the patient when she exhibits attention-seeking behavior.
- D. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: reward nonseeking attention behaviors by giving the patient unsolicited attention
The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:
- A. Fruits
- B. Salt
- C. Pepper
- D. Ketchup
Correct Answer: A
Rationale: Raw fruits may harbor bacteria, posing an infection risk for a neutropenic client on a minimal-bacteria diet.
A client with advanced Alzheimer's disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?
- A. Cough
- B. Tremors
- C. Diarrhea
- D. Pitting edema
Correct Answer: B
Rationale: Haloperidol, an antipsychotic, can cause extrapyramidal side effects like tremors, which are common and indicate a neurological side effect.
The nurse is auscultating a client's breath sounds. Low-pitched grating and rubbing are noted on inhalation and exhalation. What will the nurse chart under assessment findings?
- A. ronchi
- B. stridor
- C. friction rub
- D. fine crackles
Correct Answer: C
Rationale: Low-pitched grating/rubbing sounds indicate a pleural friction rub, often due to pleural inflammation.