Nokea
A nurse is assigned to perform well-child assessments at a day care center. A staff member interrupts the examinations to ask for assistance. They find a crying 3 year-old child on the floor with mouth wide open and gums bleeding. Two unlabeled open bottles lie nearby. The nurse's first action should be
- A. call the poison control center, then 911
- B. administer syrup of Ipecac to induce vomiting
- C. give the child milk to coat her stomach
- D. ask the staff about the contents of the bottles
Correct Answer: D
Rationale: ask the staff about the contents of the bottles. The nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called.
You may also like to solve these questions
A 60-year-old client has been hospitalized for deep vein thrombosis. The client is to be discharged on warfarin (Coumadin) 5 mg PO daily. Which statement that the client makes indicates the best understanding of the medication routine?
- A. I will take aspirin for my arthritis.
- B. I love to eat spinach salads.
- C. I will get a blood test next week.
- D. I made an appointment to have my teeth pulled.
Correct Answer: C
Rationale: Warfarin requires regular INR monitoring via blood tests to ensure therapeutic anticoagulation levels.
A newly admitted client has a diagnosis of depression. She complains of 'twitching muscles' and a 'racing heart', and states she stopped taking Zoloft a few days ago because it was not helping her depression. Instead, she began to take her partner's Parnate. The nurse should immediately assess for which of these adverse reactions?
- A. Pulmonary edema
- B. Atrial fibrillation
- C. Mental status changes
- D. Muscle weakness
Correct Answer: C
Rationale: Mental status changes. Use of serotonergic agents may result in Serotonin Syndrome with confusion, nausea, palpitations, increased muscle tone with twitching muscles, and agitation. Serotonin syndrome is most often reported in patients taking 2 or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve the MAOIs, SSRIs, and the tricyclic antidepressants.
The nurse administered an IV broad-spectrum antibiotic scheduled every six (6) hours to the client with a systemic infection at 0800. At 1000, the culture and sensitivity prompted the HCP to change the IV antibiotic. When transcribing the new antibiotic order, when would the initial dose be administered?
- A. Schedule the dose for 1400.
- B. Schedule the dose for the next day.
- C. Check with the HCP to determine when to start.
- D. Administer the dose within one (1) hour of the order.
Correct Answer: D
Rationale: New antibiotic orders for active infections require prompt administration (within 1 hour) to maintain therapeutic levels, per sepsis guidelines.
The client diagnosed with asthma is prescribed the mast cell inhibitor cromolyn. Which statement by the client indicates the need for further teaching?
- A. I will take two puffs of my inhaler before I exercise.
- B. I will rinse my mouth with water after taking the medication.
- C. After inhaling the medication, I will hold my breath for 10 seconds.
- D. When I start to wheeze, I will use my inhaler immediately.
Correct Answer: D
Rationale: Cromolyn is a prophylactic, not rescue, medication for asthma; using it during wheezing indicates misunderstanding. Pre-exercise use, breath-holding, and rinsing (though less critical) are correct.
The client is experiencing supraventricular tachycardia (SVT). Which antidysrhythmic medication should the nurse prepare to administer?
- A. Atropine.
- B. Amiodarone.
- C. Adenosine.
- D. Dobutamine.
Correct Answer: C
Rationale: Adenosine is first-line for SVT, rapidly terminating the arrhythmia, per ACLS guidelines. Other drugs are used for different rhythms.