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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates worsening in the client's condition since they are prone to infections.
B. In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C. In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D. In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E. The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.
Correct Answer is B
Explanation
A. A patient with anaphylactic reaction may have unpredictable clinical course and require immediate interventions, which could affect the stability of the roommate.
B. A patient with viral pneumonia poses a lower risk of infection transmission to an immunocompromised patient with acute organ rejection compared to other options.
C. Graft-versus-host disease indicates an immunocompromised state and poses infection risks, similar to acute rejection patients.
D. Second degree burns also pose infection risks and would not be suitable for a roommate of a patient with acute organ rejection.
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