Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

The patient frequently uses an alcohol-based sanitizer for hand hygiene.

The patient takes acetaminophen 1000 mg every 4 hours around the clock.

The patient takes alprazolam 0.25 mg every 8 hours.

The patient rinses with a fluoride mouthwash after brushing the teeth.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.

Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.

Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 8 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.

Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because "Are you having any difficulty breathing right now?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to describe their condition in detail.

Choice B reason: This is the correct choice because "What does your chest pain feel like?" is an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question invites the patient to describe the quality, intensity, location, and duration of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.

Choice C reason: This is an incorrect choice because "Do you have a family history of heart disease?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to provide more details about their health history or risk factors.

Choice D reason: This is an incorrect choice because "How long have you been experiencing chest pain?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a specific time, and does not encourage the patient to provide more information about their symptoms or situation.

A. Utilize a no-rinse shampoo cap. B. Use a handheld shower sprayer. C. Have the patient lean over the wash basin. D. Have the patient lean back into the sink.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because utilizing a no-rinse shampoo cap is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A no-rinse shampoo cap is a disposable cap that contains a pre-moistened shampoo and conditioner. It can be heated in a microwave and applied to the patient's head without the need for water or rinsing. It can clean and condition the patient's hair without causing any discomfort or movement of the affected shoulder.

Choice B reason: This is an incorrect choice because using a handheld shower sprayer is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A handheld shower sprayer is a device that attaches to a faucet and allows the user to direct the water flow. It can be difficult and painful for the patient to use or hold the sprayer with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice C reason: This is an incorrect choice because having the patient lean over the wash basin is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A wash basin is a bowl or sink that contains water and soap for washing. It can be uncomfortable and risky for the patient to lean over the basin with the affected shoulder, and it can also wet the surgical dressing or incision site.

Choice D reason: This is an incorrect choice because having the patient lean back into the sink is not the best option for washing the patient’s hair who has just undergone shoulder replacement surgery. A sink is a basin with a faucet that provides water for washing. It can be uncomfortable and risky for the patient to lean back into the sink with the affected shoulder, and it can also wet the surgical dressing or incision site.

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Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended question will provide the nurse with helpful information about the patient’s health status?

Correct Answer is B

Explanation

Which is the best option for washing the patient’s hair who has just undergone shoulder replacement surgery?

Correct Answer is A

Explanation

The nurse is caring for a patient who will be having surgery shortly. The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome. Which is the most appropriate action of the nurse?

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