A nurse is caring for a client who has had a sedative overdose. What is the priority action in caring for this client?
Identify the type of sedative.
Insert a large-bore IV catheter.
Ensure an adequate airway.
Prepare the appropriate antagonist.
The Correct Answer is C
A: Identifying the type of sedative is important for treatment but is not the immediate priority.
B: Inserting a large-bore IV catheter is necessary for administering medications and fluids but is not the first priority.
C: Ensuring an adequate airway is the priority action. Maintaining airway patency is crucial to prevent respiratory complications and ensure the client receives adequate oxygen.
D: Preparing the appropriate antagonist is important but should follow the immediate action of ensuring an adequate airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Pulling the auricle upward and outward is the correct technique for adults and children over 3 years old, not for a 2-year-old child.
B: Pulling the auricle down and back is the correct technique for straightening the ear canal in children under 3 years old. This allows for proper administration of the eardrops.
C: Sitting the child up to insert a cotton ball into the innermost ear canal is not appropriate. Cotton balls should not be inserted deeply into the ear canal.
D: Sitting the child up for 2 to 3 minutes after instilling drops is not necessary. The child should remain in a position that allows the drops to stay in the ear canal for the prescribed time.
Correct Answer is B
Explanation
A: A drop in systolic blood pressure of 10 mm Hg (from 140 to 130) does not meet the criteria for orthostatic hypotension, which requires a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.
B: This finding shows a drop in systolic blood pressure from 130 to 110 mm Hg, which is a 20 mm Hg decrease. This meets the criteria for orthostatic hypotension, indicating that the patient may have this condition.
C: A drop in systolic blood pressure of 6 mm Hg (from 126 to 120) does not meet the criteria for orthostatic hypotension. The decrease is not significant enough to confirm the condition.
D: An increase in blood pressure (from 130/64 to 140/70) does not indicate orthostatic hypotension. This finding suggests that the patient’s blood pressure increases upon standing, which is not consistent with orthostatic hypotension.
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