Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

Prepare a 60-mL syringe with saline.

Assist with intubation of the patient.

Give first dose of activated charcoal.

Insert a large-bore orogastric tube.

Answer and Explanation

The Correct Answer is B

A. Preparing a 60-mL syringe with saline may be necessary for gastric lavage but is not the first action.
B. For an unconscious patient who has ingested a significant quantity of lorazepam, securing the airway is the most critical first step to prevent aspiration and ensure the patient can breathe. Therefore, the nurse should assist with intubation of the patient.
C. The initial step is to ensure that the client’s airway is secured through intubation before administration of activated charcoal.
D. Inserting a large-bore orogastric tube may be necessary for gastric lavage but typically follows administration of activated charcoal.

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Correct Answer is ["A","B","E","F"]

Explanation

A. Tenderness in the area of the transplant incision can be a sign of inflammation or rejection.
B. Bilateral edema (swelling) in the lower legs can be a sign of fluid retention, which can occur with kidney dysfunction or rejection.
C. While high blood pressure can be a concern, it's not a specific indicator of transplant rejection in this scenario.
D. The sodium level is within normal limits in this case, decreasing the risk of a transplant rejection.
E. An elevated creatinine level can indicate worsening kidney function, which could be a sign of rejection.
F. Hypoactive bowel sounds in all four quadrants can suggest decreased blood flow or intestinal ischemia, which can be a complication of transplant rejection.
G. Normal lung sounds are not necessarily indicative of rejection.

A. Place the client's clothing in a plastic bag. B. Instruct the client to remove their clothing. C. Remain at least 1.8 meters (6 feet) from the client D. Shower and scrub the client's skin

Correct Answer is B

Explanation

A. Placing the client's clothing in a plastic bag may be necessary for preserving evidence but does not address immediate safety concerns.
B. Instructing the client to remove their clothing helps reduce further exposure to the unknown chemical.
C. Maintaining a safe distance from the client is important, but immediate decontamination is a higher priority.
D. Showering and scrubbing the client's skin should be done after removing contaminated clothing to minimize exposure.

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Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is admitted to the emergency department for fatigue. Exhibits Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

Correct Answer is ["A","B","E","F"]

Explanation

A nurse is caring for a client who has been exposed to an unknown chemical. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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?

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include?

The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?