A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

Start oxygen using a non-rebreather mask,

Have the patient drink large amounts of water.

Give N-acetylcysteine.

Discuss the use of chelation therapy.

Answer and Explanation

The Correct Answer is C

A. Oxygen administration is not indicated for acetaminophen overdose unless respiratory distress is present.
B. Drinking water does not address acetaminophen overdose and its potential liver toxicity.
C. N-acetylcysteine is the antidote for acetaminophen overdose and should be administered to prevent liver damage.
D. Chelation therapy is not used in the treatment of acetaminophen overdose.

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Correct Answer is C

Explanation

A. While painful, a simple fracture and scratches do not pose an immediate threat to life compared to other injuries.
B. The client with severe head injuries and a low respiratory rate may seem like a priority, but if they are unresponsive and have a respiratory rate as low as 6/min, they may be beyond help.
C. A punctured chest with an audible hissing sound indicates a potential tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent collapse of the lung and other potentially fatal complications.
D. A pregnant woman with cuts and abrasions should be evaluated promptly but is not as critical as clients with severe head injuries or tension pneumothorax.

A. Monitor the client's vital signs once every 8 hr. B. Provide the client with 1,000 mL of water to drink every 12 hr C. Keep blood pressure equipment in the client's room. D. Place the client in a negative airflow room.

Correct Answer is C

Explanation

A. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Clients undergoing stem cell transplants are immunocompromised due to chemotherapy and conditioning regimens. To reduce the risk of infection, all equipment that comes into contact with the client, such as blood pressure cuffs, should be dedicated to that room only. This prevents cross-contamination from other patients.
D. Negative pressure rooms are for protecting others from airborne infections (e.g., TB). Stem cell transplant clients require positive pressure rooms to protect them from pathogens in the environment.

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A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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