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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A: Calling the prescribing physician is important, but the immediate action should be to withhold the medication to prevent further elevation of potassium levels.

B: Calling the lab to verify the results can be done, but the immediate action should be to withhold the medication.

C: Omitting the KCL dose and documenting it is the correct action. The client’s potassium level is already elevated, and administering additional potassium could be harmful.

D: Giving the ordered KCL as prescribed is not appropriate because the client’s potassium level is already above the normal range.

A. Check the display on the PCA pump. B. Obtain an order for another pain medication for breakthrough pain. C. Administer a bolus of medication. D. Encourage the client to administer a demand dose.

Correct Answer is A

Explanation

A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.

B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.

C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.

D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.

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A nurse is caring for a client who has had a sedative overdose. What is the priority action in caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. (Normal 3.5-5.0 mEq/L) Which action should the nurse take?

Correct Answer is C

Explanation

A nurse caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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