A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication.
The client has prescriptions for an anxiolytic and an SSRI antidepressant.
Which of the following precautions should the nurse take?.
Restrict interactions with other clients
Document the client's behavior every 2 hr.
Implement 24-hr one-to-one nursing observation.
Administer prescribed medication via the IM route.
The Correct Answer is C
Choice A rationale:
Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.
Choice B rationale:
Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.
Choice C rationale:
Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.
Choice D rationale:
Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
The correct answer is 2.5 mL. Calculation: Identify the desired dose: 50 mg Identify the available dose: 20 mg/mL Apply the formula: Desired ÷ Available = Volume to administer Calculation: 50 mg ÷ 20 mg/mL = 2.5 mL
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. Aripiprazole is an antipsychotic medication and is not used for smoking cessation.
Choice B rationale:
This statement is correct. Bupropion is an antidepressant that has been shown to be effective in helping people quit smoking.
Choice C rationale:
This statement is incorrect. Quetiapine is an antipsychotic medication and is not used for smoking cessation.
Choice D rationale:
This statement is incorrect. Risperidone is an antipsychotic medication and is not used for smoking cessation.
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