A nurse is planning care for a client who is undergoing alcohol withdrawal and is receiving diazepam. Which of the following interventions should the nurse include in the plan?
Administer the medication subcutaneously.
Initiate seizure precautions.
Administer the medication with an antacid.
Initiate contact precautions.
The Correct Answer is B
A. Administer the medication subcutaneously – Diazepam should be given orally or intravenously in severe cases, not subcutaneously.
B. Initiate seizure precautions – This is the correct answer. Alcohol withdrawal can lead to seizures due to central nervous system hyperactivity. Diazepam, a benzodiazepine, is used to prevent seizures and manage withdrawal symptoms.
C. Administer the medication with an antacid – There is no need to administer diazepam with an antacid; doing so can interfere with absorption.
D. Initiate contact precautions – Alcohol withdrawal is not an infectious condition, so contact precautions are unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct answer. Older adults are at risk for fluid overload, so infusing blood over 4-5 hours (instead of the usual 2-4 hours) is safer.
B. Blood products must be infused with 0.9% sodium chloride (normal saline) only. Dextrose-containing solutions cause hemolysis.
C. A 20-gauge catheter is acceptable, but a larger bore (18-gauge) is preferred for faster infusion.
D. Vital signs should be monitored before the transfusion, 15 minutes after starting, then every 30-60 minutes, and at completion.
Correct Answer is D
Explanation
A. Empty the collection chamber every 8 hr – Incorrect. The collection chamber is not emptied; instead, it is replaced when full to prevent air re-entry.
B. Check the patency of the tubing every 2 hr – While monitoring the tubing is essential, checking patency is not the most specific nursing priority.
C. Keep the drainage system above the level of the client's chest – Incorrect. The system should remain below chest level to prevent backflow of drainage.
D. Ensure 2 cm (0.8 in) of water is in the water seal chamber – Correct. The water seal chamber maintains negative pressure and prevents air from entering the pleural space, making this a crucial step in chest tube management.
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