Nokea
What is the priority intervention for a 16-year-old client with a history of depression who is brought to the emergency department after taking an overdose of acetaminophen?
- A. Administer activated charcoal
- B. Place the client on continuous cardiac monitoring
- C. Prepare for gastric lavage
- D. Administer N-acetylcysteine as prescribed
Correct Answer: D
Rationale: The priority intervention for a client who has taken an acetaminophen overdose is to administer N-acetylcysteine promptly. N-acetylcysteine is the antidote for acetaminophen overdose and helps prevent liver damage. Activated charcoal may be used in certain cases, but N-acetylcysteine takes precedence as it directly counteracts the toxic effects of acetaminophen. Continuous cardiac monitoring and gastric lavage are not the priority interventions for acetaminophen overdose. Administering N-acetylcysteine is crucial to prevent liver damage and address the overdose, making it the most urgent action in this scenario.
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The mother of an 11-year-old boy with juvenile arthritis tells the nurse, 'I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting.' Which information is most important for the nurse to provide this mother?
- A. The child should be encouraged to rest when experiencing pain
- B. Encourage quiet activities such as reading as a pain distracter
- C. The use of hot baths can be used as an alternative to pain medication
- D. Giving pain medication around the clock helps control the pain
Correct Answer: D
Rationale: It is crucial for the nurse to educate the mother that giving pain medication around the clock helps manage pain effectively and improves the child's quality of life. This approach ensures a more consistent level of pain relief and prevents the pain from becoming severe, which can be more challenging to manage. Choices A, B, and C do not address the importance of consistent pain management and may not provide adequate relief for the child's condition.
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 100 mL in the last 8 hours.
- B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
- C. Serum potassium of 3.0 mEq/L.
- D. Serum pH of 7.45.
Correct Answer: C
Rationale: A serum potassium level of 3.0 mEq/L is significantly low and indicates hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Therefore, it is crucial for the nurse to report this finding promptly to the healthcare provider for immediate intervention. The other findings are not as critical in this situation. Gastric output of 100 mL in the last 8 hours may be expected in a patient with persistent vomiting. The shift intake of IV fluids and ice chips indicates fluid replacement, which is important but not as urgent as correcting electrolyte imbalances. A serum pH of 7.45 is within the normal range and does not indicate an immediate concern.
What intervention should the nurse implement first for a male toddler brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin)?
- A. Administer activated charcoal orally
- B. Prepare gastric lavage
- C. Obtain a 12-lead electrocardiogram
- D. Give IV digoxin immune fab (Digibind)
Correct Answer: D
Rationale: In cases of digoxin toxicity, IV digoxin immune fab (Digibind) is the antidote and should be administered first to counteract the effects of digoxin poisoning. This intervention is crucial in managing digoxin overdose and should be initiated promptly to improve patient outcomes. Activated charcoal and gastric lavage are not effective in treating digoxin poisoning and may not be beneficial at this stage. While obtaining an electrocardiogram is important to assess cardiac function, administering the antidote should take precedence to address the immediate life-threatening effects of digoxin toxicity.
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Place the child in a quiet environment
- B. Make a list of foods that the child likes
- C. Encourage the parents to rest when possible
- D. Apply lotion to hands and feet
Correct Answer: A
Rationale: The correct intervention for a child with Kawasaki disease, presenting with irritability and skin peeling, is to place the child in a quiet environment. This helps reduce environmental stimuli, calming the child and aiding in managing the symptoms associated with the disease. Choice B is incorrect as addressing food preferences is not the priority in this situation. Choice C is incorrect as the focus should be on the child's immediate needs. Choice D is incorrect as applying lotion is not the first-line intervention for Kawasaki disease symptoms.
A school-age child with a history of type 1 diabetes mellitus is brought to the emergency department with confusion and rapid breathing. The practical nurse (PN) suspects diabetic ketoacidosis (DKA). Which initial intervention should the PN anticipate?
- A. Administer subcutaneous insulin.
- B. Give oral glucose tablets.
- C. Start intravenous fluids.
- D. Administer oxygen therapy.
Correct Answer: C
Rationale: Intravenous fluids are typically the initial intervention in diabetic ketoacidosis (DKA) to treat dehydration and stabilize the patient's condition. The fluid replacement helps correct electrolyte imbalances and improve perfusion, which are crucial in managing DKA. Insulin therapy follows after fluid resuscitation to address the underlying cause of DKA, which is the lack of insulin leading to increased ketone production. Administering subcutaneous insulin (Choice A) would be premature without first addressing the dehydration and electrolyte imbalances. Giving oral glucose tablets (Choice B) is contraindicated in DKA as the patient already has high blood glucose levels. Administering oxygen therapy (Choice D) may be necessary based on the patient's condition, but addressing dehydration with intravenous fluids is the priority intervention in DKA.