Nokea
The nurse is caring for a patient admitted to the hospital after an automobile accident who has a blood alcohol concentration (BAC) of 48 mmol/L (0.22 mg%). The patient is alert and does not appear highly intoxicated. Which of the following nursing actions should the nurse implement?
- A. Maintain the patient on NPO status.
- B. Avoid the use of intravenous (IV) fluids.
- C. Administer acetaminophen for headache.
- D. Monitor frequently for anxiety, hyper-reflexia, and sweating.
Correct Answer: D
Rationale: The patient's assessment data indicate physiological dependence on alcohol, and the patient is likely to develop acute withdrawal such as anxiety, hyper-reflexia, and sweating, which could be life-threatening. Acetaminophen is not recommended because it is metabolized by the liver. IV thiamine and IV glucose solutions usually are given to intoxicated patients to prevent Wernicke's encephalopathy, and there is no indication that the patient should be NPO.
You may also like to solve these questions
The nurse is caring for a young adult patient who has inhaled cocaine and has been admitted to the emergency department with palpitations and shortness of breath. Which of the following actions ordered by the health care provider will the nurse implement first?
- A. Obtain a 12-lead ECG.
- B. Start O2 at 4 L/minute.
- C. Draw blood for drug screening.
- D. Infuse normal saline at 100 mL/hour.
Correct Answer: B
Rationale: The priority here is to ensure that oxygenation is adequate. The other orders also should be accomplished as soon as possible but are not the first priority.
A patient with a history of heavy alcohol use is seen at the clinic with acute gastritis. Which statement by the patient indicates that the patient is in the contemplation stage of change?
- A. I am older and wiser now, and I know I can change my drinking behaviour.
- B. Alcohol has never bothered my stomach. I think it's likely that I have the flu.
- C. I think my drinking is affecting my stomach, but maybe some drugs will help.
- D. People say that I drink too much, but I really feel pretty good most of the time.
Correct Answer: C
Rationale: This statement indicates that the patient recognizes that alcohol use is the reason for the gastritis but is not yet willing to make a change. The statement 'I am older and wiser now, and I know I can change my drinking behaviour' indicates a patient at the preparation stage. The remaining two statements are typical of the precontemplation stage.
The nurse is caring for a patient who smokes a pack of cigarettes daily and has been admitted to the hospital for surgery. In anticipation of nicotine withdrawal, which of the following goals should the nurse include when planning postoperative care?
- A. Improve sleep.
- B. Enhance appetite.
- C. Decrease diarrhea.
- D. Prevent sore throat.
Correct Answer: A
Rationale: Insomnia is a characteristic of nicotine withdrawal. Diarrhea, sore throat, and anorexia are not symptoms associated with nicotine withdrawal.
An older adult has been taking alprazolam and calls the clinic asking for a refill of the prescription 1 month before it should need to be refilled. Which of the following responses is most appropriate?
- A. The prescription cannot be refilled for another month. What happened to all of your pills?
- B. Do you have any muscle cramps or tremors if you don't take the medication frequently?
- C. I will ask the doctor to prescribe a few more pills, but you will not be able to get any more for another month.
- D. I am concerned that you may be overusing the alprazolam. Let's make an appointment for you to see the doctor today.
Correct Answer: D
Rationale: The patient should be assessed for problems that are causing overuse of the alprazolam, such as anxiety or memory loss. The other responses by the nurse will not allow for the needed assessment and possible referral for support services or treatment of drug dependence.
The nurse is caring for a patient with alcohol dependence who has been admitted to the hospital with chest pain. Twenty-four hours after admission, the patient becomes very tremulous and anxious. Which of the following actions should the nurse implement?
- A. Insert an IV line and infuse fluids.
- B. Promote oral intake to 3000 mL/day.
- C. Provide a quiet, well-lit environment.
- D. Administer opioids to provide sedation.
Correct Answer: C
Rationale: The patient's symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help to decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible.