A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?

Initiate vomiting and apply an enema.

Check pupil size and reflexes.

Establish a patent airway.

Administer IV fluids fast.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Initiating vomiting and applying an enema is not the first action to take when finding an unconscious person. This could potentially cause more harm, especially if the person is unconscious as they could choke. It’s also important to note that inducing vomiting is not a recommended procedure for drug overdoses as it can lead to aspiration, which can cause more harm.

Choice B rationale: Checking pupil size and reflexes is important in assessing a patient’s neurological status. However, it is not the first action to take. The first action should always be to ensure the patient has a patent airway to allow for adequate oxygenation.

Choice C rationale: Establishing a patent airway is the correct first action when finding an unconscious person. This is because maintaining a patent airway is crucial for oxygenation and ventilation. Without a patent airway, the person could suffer from hypoxia, which could lead to brain damage or death.

Choice D rationale: Administering IV fluids fast is not the first action to take when finding an unconscious person. While IV fluids may be necessary later on in the management of the patient, the first action should always be to ensure the patient has a patent airway.

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Correct Answer is ["15"]

Explanation

Question: How many mL should the nurse administer per dose?

Step 1: 150 mg ÷ 50 mg

Step 2: 3 × 5 mL

Answer: 15 mL per dose.

A. Administer 0.9% sodium chloride IV. B. Administer IV flumazenil. C. Prepare the client for intubation. D. Begin chest compressions E. Administer IV naloxone. F. Administer activated charcoal. G. Prepare the client for electroconvulsive therapy (ECT).

Correct Answer is ["A","E","G"]

Explanation

The correct answer/s is Choice/s A, E, and G.

Choice A rationale: Administering 0.9% sodium chloride IV is a common practice in emergency departments to ensure the patient is well-hydrated. This is particularly important for patients experiencing acute mania, as they may have neglected their physical health, including hydration, during their manic episode.

Choice B rationale: Flumazenil is an antagonist for benzodiazepines and is typically used to reverse the sedative effects of benzodiazepines. It is not typically used in the treatment of bipolar disorder or acute mania.

Choice C rationale: Preparing the client for intubation is usually reserved for situations where the patient is unable to maintain their own airway or adequate ventilation. This is not typically necessary in cases of acute mania unless there are other complicating factors.

Choice D rationale: Beginning chest compressions is a response to cardiac arrest. There is no indication in the that the patient is experiencing cardiac arrest, so this would not be a typical anticipation for a patient experiencing acute mania.

Choice E rationale: Administering IV naloxone is done in cases of suspected opioid overdose. While it’s not directly related to treating acute mania, it’s possible that the patient could have comorbid substance use issues, given the high rate of comorbidity between bipolar disorder and substance use disorders.

Choice F rationale: Administering activated charcoal is done in cases of certain types of poisoning or drug overdose. It is not typically used in the treatment of bipolar disorder or acute mania.

Choice G rationale: Preparing the client for electroconvulsive therapy (ECT) could be an appropriate anticipation for a patient experiencing acute mania. ECT is considered a highly effective treatment for severe mania, particularly when other treatments have failed or when rapid stabilization is required.

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A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amantadine 150 mg PO every 12 hr. The available medication is amantadine 50 mg/5 mL syrup. How many mL should the nurse administer per dose?

Correct Answer is ["15"]

Explanation

A nurse is caring for a client in the emergency department (ED). The client comes to the ED via ambulance. The client has a history of bipolar disorder and is experiencing acute mania. Select the 3 prescriptions that the nurse should anticipate for this client.

Correct Answer is ["A","E","G"]

Explanation

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