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 D

Explanation

A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.

A. Give acetaminophen (Tylenol) rectal suppository. B. Provide O2 at 2 L/min with a nasal cannula. C. Apply wet sheets and a fan to the patient D. Start lactated Ringer's solution at 1000 mL/hr

Correct Answer is C

Explanation

A. Giving acetaminophen is appropriate for fever reduction but does not address the hypotension and potential dehydration in this scenario.
B. Providing oxygen is important, but the patient's hypotension requires fluid resuscitation as the initial priority.
C. Applying wet sheets and a fan are immediate actions focused on rapid cooling. The priority is to lower the body temperature as quickly as possible to prevent organ damage.
D. Starting lactated Ringer's solution at a high rate is crucial to address hypovolemia and to cool the patient effectively through intravenous hydration but should be done after cooling the patient using a wet sheet.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4" F (40.8" C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

Correct Answer is C

Explanation

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