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?
Administer a stimulant to the client.
Administer a diuretic to the client.
Measure the client's urine specific gravity.
Insert an NG tube for the client.
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.
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Related Questions
Correct Answer is C
Explanation
A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.
Correct Answer is B
Explanation
A. Polyuria. Increased urination is not a common adverse effect of clozapine and does not require immediate reporting.
B. Fever. Clozapine can cause agranulocytosis, a serious condition that suppresses white blood cell production. Fever may indicate infection, which requires immediate evaluation.
C. Diarrhea. Gastrointestinal symptoms can occur with clozapine but are not typically urgent unless severe or persistent.
D. Diaphoresis. Excessive sweating is a possible side effect but does not require immediate medical attention.
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