A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?
Obtain a serum drug screen.
Administer naloxone per PRN protocol.
Initiate seizure precautions.
Instruct the family about withdrawal symptoms.
The Correct Answer is C
Choice A rationale
While obtaining a serum drug screen might be helpful in confirming the presence of benzodiazepines or other substances, it is not the most immediate concern in a client experiencing severe agitation and tremors due to withdrawal.
Choice B rationale
Naloxone is an opioid antagonist and would not be effective in managing withdrawal symptoms from benzodiazepines.
Choice C rationale
Seizure precautions should be initiated as withdrawal from benzodiazepines can lead to severe withdrawal symptoms, including seizures. Therefore, ensuring the safety of the client by initiating seizure precautions is the best initial nursing action.
Choice D rationale
While education is an important part of nursing care, in this situation, the client’s immediate physical needs take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.80"]
Explanation
Step 1 is to convert the patient’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.20462 pounds. So, the patient’s weight in kilograms is 132 pounds ÷ 2.20462 = 59.87 kg.
Step 2 is to calculate the total dosage of dantrolene needed. The prescribed dosage is 1.5 mg/kg. So, the total dosage is 1.5 mg/kg × 59.87 kg = 89.81 mg.
Step 3 is to calculate the volume of reconstituted dantrolene solution needed to provide the total dosage. The reconstituted solution has a concentration of 50 mg/mL. So, the volume needed is 89.81 mg ÷ 50 mg/mL = 1.80 mL.
Correct Answer is C
Explanation
Choice A rationale
While seizure precautions are important for clients receiving certain medications or with certain conditions, they are not typically necessary for clients receiving dopamine. Dopamine, an adrenergic agonist, does not typically increase the risk of seizures.
Choice B rationale
Assessing pupillary response to light hourly is not typically necessary for clients receiving dopamine. Dopamine does not typically affect pupillary response.
Choice C rationale
Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine at low to moderate doses can dilate renal blood vessels, which can increase urine output. Therefore, monitoring urinary output can help assess the effectiveness of the medication and the client’s renal perfusion.
Choice D rationale
While it is important to monitor electrolyte levels in clients receiving certain medications, frequent monitoring of serum potassium is not typically necessary for clients receiving dopamine. Dopamine does not typically affect serum potassium levels.
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