A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 minutes ago.
The client is lethargic and has a respiratory rate of 10/min.
After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?
Evaluate the client for further suicidal behavior.
Administer flumazenil to the client.
Monitor the client's IV site for thrombophlebitis.
Initiate seizure precautions for the client.
The Correct Answer is B
= Answer is... Choice B. Administer flumazenil to the client.
Choice A rationale:
In the emergency department scenario described, the client has presented with symptoms suggestive of a diazepam overdose, indicating potential suicidal behavior. However, while evaluating the client for further suicidal behavior is an important aspect of comprehensive care, it is not the immediate priority in this situation. The client's lethargy and respiratory depression require urgent intervention to reverse the effects of diazepam overdose and stabilize their condition. Once the client's immediate medical needs are addressed, further assessment and intervention regarding suicidal behavior can be pursued as part of ongoing care and safety planning.
Choice B rationale:
Administering flumazenil to the client is the most appropriate next action in the management of a diazepam overdose. Flumazenil, a benzodiazepine receptor antagonist, effectively reverses the sedative effects of benzodiazepines such as diazepam by competitively blocking benzodiazepine binding sites on the gamma-aminobutyric acid (GABA) receptor complex. By antagonizing the effects of diazepam, flumazenil can rapidly restore consciousness and respiratory drive in clients experiencing benzodiazepine-induced central nervous system depression, such as lethargy and hypoventilation. Prompt administration of flumazenil is crucial for preventing further respiratory compromise and potential respiratory arrest in overdose situations.
Choice C rationale:
Monitoring the client's IV site for thrombophlebitis is an important aspect of nursing care during IV therapy; however, it is not the immediate priority in this scenario. While maintaining IV access is essential for administering medications and fluids, including flumazenil in this case, the urgent need to reverse the effects of diazepam overdose takes precedence over monitoring for IV complications. Thrombophlebitis can be assessed and managed concurrently with the administration of flumazenil and other aspects of the client's care once their immediate medical condition is stabilized.
Choice D rationale:
Initiating seizure precautions for the client may be warranted in certain clinical situations, particularly if the client has a history of seizures or if there are concerns about potential withdrawal or rebound seizures following the administration of flumazenil. However, in the context of a diazepam overdose with central nervous system depression and lethargy, the primary focus is on reversing the effects of the overdose and restoring respiratory function. Seizure precautions can be implemented if indicated based on ongoing assessment and clinical judgment but are not the immediate next action following initiation of IV access and administration of flumazenil.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: b. Determine goals of the day.
Choice A: Schedule daily activities.
Rationale: Scheduling daily activities is crucial for time management but should follow establishing goals. The nurse must first determine the priorities and objectives for the day before organizing the tasks.
Choice B: Determine goals of the day.
Rationale: Identifying the goals of the day is the first step in effective time management for a nurse. This enables the nurse to prioritize patient care and other responsibilities, ensuring that essential tasks are accomplished and patient needs are met. Goals can include completing assessments, administering medications, and attending to patient concerns.
Choice C: Delegate tasks to the AP.
Rationale: Delegating tasks is vital in managing time and resources, but it should occur after the goals and priorities are determined. The nurse must first know which tasks need to be completed before assigning responsibilities to the LPN and AP.
Choice D: Develop an hourly time frame for tasks.
Rationale: Creating a timeline for tasks is essential for time management but should be done after setting goals and prioritizing tasks. This will enable the nurse to allocate an appropriate amount of time for each task and help ensure that all necessary tasks are completed within the shift.
In conclusion, by first determining the goals of the day, the nurse can effectively manage time and ensure that all essential tasks are completed. Prioritizing patient care and other responsibilities will enable the nurse to collaborate effectively with the LPN and AP in delegating tasks and scheduling activities.
Correct Answer is B
Explanation
The correct answer is Choice B: "When using implanted contraceptive methods, condoms should also be used to protect against STDs."
Choice B rationale: While implanted contraceptive methods are highly effective in preventing unintended pregnancies, they do not provide protection against sexually transmitted diseases (STDs). Therefore, using condoms in conjunction with implanted contraceptives can enhance overall sexual health by reducing the risk of contracting or transmitting STDs. This statement highlights the nurse's understanding of the importance of comprehensive sexual health practices and the limitations of various contraceptive methods.
Choice A rationale: The use of petroleum-based lubricants with condoms can actually compromise their effectiveness. Petroleum-based lubricants can degrade latex condoms, increasing the likelihood of condom breakage or slippage, which in turn raises the risk of both pregnancy and STD transmission.
Choice C rationale: Condoms are indeed effective in preventing pregnancy, but their effectiveness can be enhanced by using them in conjunction with vaginal spermicides. Spermicides containing nonoxynol-9 can provide additional protection by inactivating or killing sperm, thus reducing the risk of pregnancy.
Choice D rationale: Ensuring a proper fit is crucial for a condom's effectiveness, but the statement only emphasizes the condom fitting snugly over the tip of the penis. For optimal protection, a condom should be unrolled to cover the entire erect penis, leaving a small empty space at the tip for semen collection. A condom that is not unrolled completely may be more likely to slip off or break during intercourse.
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