How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who is experiencing acute alcohol toxicity. Which of the following actions should the nurse include in the plan?

A.

Administer a stimulant to the client.

B.

Administer a diuretic to the client.

C.

Measure the client's urine specific gravity.

D.

Insert an NG tube for the client.

Answer and Explanation

The Correct Answer is C

A. Stimulants should not be administered to clients with acute alcohol toxicity, as they can increase agitation and cardiovascular stress.
B. Diuretics are not used for alcohol toxicity because they do not effectively eliminate alcohol and may contribute to dehydration.
C. Measuring urine specific gravity helps assess hydration status and kidney function, which can be affected by acute alcohol toxicity.
D. An NG tube is not routinely indicated unless the client is at risk for aspiration or requires gastric lavage due to severe intoxication.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Anticipated Interventions:

  • Initiate an IV infusion of lactated Ringer's
  • Place the client in a left lateral position
  • Maintain continuous monitoring of the FHR

Contraindicated Intervention:

  • Monitor blood pressure every hour

Rationale:

  • Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
  • Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
  • Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
  • Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.

Correct Answer is B

Explanation

A. Allergic. Symptoms of an allergic reaction to a blood transfusion typically include itching, rash, and hives rather than chills, headache, or low-back pain.
B. Acute hemolytic. This reaction occurs when the client receives incompatible blood, leading to red blood cell destruction. Symptoms include chills, headache, low-back pain, chest tightness, hypotension, and fever.
C. Bacterial. A bacterial transfusion reaction is usually caused by contaminated blood products and presents with fever, chills, hypotension, and possible sepsis. The described symptoms suggest a different reaction.
D. Febrile nonhemolytic. This reaction is more common and presents with fever, chills, and headache but does not typically include low-back pain or chest tightness, which are more indicative of an acute hemolytic reaction.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register