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.

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.

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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.

A. Choose the client's dominant arm for IV access whenever possible. B. Select a site proximal to previous venipuncture sites. C. Initiate IV access on the palmar side of the client's wrist. D. Insert a larger gauge IV catheter to prevent phlebitis.

Correct Answer is B

Explanation

A. Choose the client's dominant arm for IV access whenever possible. The nondominant arm is preferred to minimize interference with daily activities.
B. Select a site proximal to previous venipuncture sites. This is the appropriate action because using a site above a previous one ensures better vein integrity and reduces complications.
C. Initiate IV access on the palmar side of the client's wrist. This site should be avoided as it is more painful and increases the risk of nerve damage.
D. Insert a larger gauge IV catheter to prevent phlebitis. A smaller gauge catheter is preferred when possible, as larger catheters can increase the risk of vein irritation and phlebitis.

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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?

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