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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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}
Explanation
- This prescription helps maintain oral hygiene and comfort, which is important during chemotherapy to prevent and manage mucositis.
- Routine daily temperature checks may not be necessary unless there are specific concerns about infection or fever.
- Placing the client in a private room can reduce the risk of infection, which is crucial due to the client's immunocompromised state from chemotherapy.
- Unless there is a specific medical indication (e.g., urinary retention), inserting an indwelling urinary catheter increases the risk of infection, which should be minimized in an immunocompromised client.
- Droplet precautions are typically used for respiratory infections transmitted by large droplets. Lung cancer itself does not typically require droplet precautions unless there is an active respiratory infection.
Correct Answer is B
Explanation
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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