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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"}}
No explanation
Correct Answer is B
Explanation
The correct answer is choice b. “I will hang a new bag of TPN and IV tubing every 24 hours.”
Choice A rationale:
Monitoring the client’s blood glucose level every 8 hours is important, but it is not the best indicator of understanding the TPN procedure. Blood glucose levels should be monitored regularly, but the frequency can vary based on the client’s condition and physician’s orders.
Choice B rationale:
Hanging a new bag of TPN and IV tubing every 24 hours is correct. This practice helps prevent infection and ensures the client receives the correct formulation of nutrients.
Choice C rationale:
Increasing the rate of the TPN infusion to ensure the correct amount is given is incorrect. The rate of TPN infusion should be strictly controlled and adjusted only by a physician’s order to prevent complications such as hyperglycemia or fluid overload.
Choice D rationale:
Obtaining the client’s weight every other day is important for monitoring nutritional status, but it does not directly indicate an understanding of the TPN procedure. Daily weights are often recommended to closely monitor the client’s response to TPN.
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