A 14-year-old patient is brought unconscious to the emergency room. It is suspected that the patient has deliberately taken an overdose of acetaminophen with 1/2 pint of vodka. The healthcare provider prescribes several interventions. Which intervention should the nurse question?
Monitor breathing pattern at 15-minute intervals.
Insert indwelling Foley catheter for straight drainage.
IV D5/45 NS at 100 mL/hr.
Syrup of ipecac 30 mL, po, Stat.
The Correct Answer is D
Choice A rationale:
Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.
Choice B rationale:
Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.
Choice C rationale:
Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.
Choice D rationale:
The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
High levels of structure will cause behavioral problems is incorrect. Structure and routine often provide a sense of security for children with autism and can help minimize behavioral challenges.
Choice B rationale:
Negative reinforcement works better than positive reinforcement is not accurate. Positive reinforcement is generally more effective in promoting desired behaviors in children with autism.
Choice C rationale:
Strict dietary modifications can sometimes cure autism is a misconception. While a balanced diet can positively impact overall health, there is no dietary cure for autism spectrum disorder.
Choice D rationale:
Level of functioning varies significantly among children with autism is crucial information for parents. Autism is a spectrum disorder, leading to a wide range of abilities and challenges. Tailoring interventions to the child's specific needs is important.
Correct Answer is C
Explanation
Choice A rationale:
While maintaining a moist oral mucosa is important, preventing infection takes precedence, as infections can lead to serious complications and compromise overall health.
Choice B rationale:
Increasing physical mobility is a valid goal, but infection prevention is more critical, especially when starting prednisone therapy, which can weaken the immune response.
Choice C rationale:
The priority lies in keeping the patient free of infection. Prednisone can suppress the immune system, making the patient more susceptible to infections that can have severe consequences.
Choice D rationale:
Ingesting a moderate potassium diet is important, but the prevention of infection takes precedence due to the potential for serious health risks associated with compromised immunity.
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