Nokea
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Teach mother poison prevention techniques.
- D. Place child on respiratory assistance.
Correct Answer: A
Rationale: The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. The mother's anxiety is probably so high that preventive guidance will be ineffective. Respiratory assistance is not needed if the child's respiratory function is unaltered.
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Which of the following findings would be expected in the infant with biliary atresia?
- A. Rapid weight gain and hepatomegaly
- B. Dark stools and poor weight gain
- C. Abdominal distention and poor weight gain
- D. Abdominal distention and rapid weight gain
Correct Answer: C
Rationale: Biliary atresia causes bile flow obstruction, leading to abdominal distention (from hepatomegaly) and poor weight gain due to malabsorption. Stools are pale, not dark, and weight gain is not rapid.
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:
- A. Advise the mother not to give her aspirin
- B. Ask if the client is allergic to aspirin before giving further information
- C. Assess the function of the client's cranial nerve VIII
- D. Check the aspirin bottle label to determine milligrams per tablet
Correct Answer: A
Rationale: Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children and adolescents should not be given aspirin. Allergy to aspirin is not related to Reye's syndrome. Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome. A 6-year-old child should not be given any baby aspirin.
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerostomia
- B. Candidiasis
- C. Leukoplakia
- D. Stomatitis
Correct Answer: C
Rationale: Leukoplakia cannot be rubbed off.
The nurse is caring for a client with a history of a pulmonary embolism who is receiving Lovenox (enoxaparin). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Enoxaparin, a low-molecular-weight heparin, increases bleeding risk, requiring monitoring for signs like bruising or hematuria. Hypertension, tachypnea, and fever are not primary concerns.
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
- A. Hypotension
- B. Photosensitivity
- C. Excessive appetite
- D. Dryness of the mouth
Correct Answer: B
Rationale: Protection from the sun is important in clients taking phenothiazines like chlorpromazine because they burn easily and severely.