A 14-year-old patient is brought unconscious to the emergency room. It is suspected that the patient has deliberately taken an overdose of acetaminophen with 1/2 pint of vodka. The healthcare provider prescribes several interventions. Which intervention should the nurse question?

Monitor breathing pattern at 15-minute intervals.

Insert indwelling Foley catheter for straight drainage.

IV D5/45 NS at 100 mL/hr.

Syrup of ipecac 30 mL, po, Stat.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.

Choice B rationale:

Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.

Choice C rationale:

Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.

Choice D rationale:

The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.

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Correct Answer is D

Explanation

Choice A rationale:

Instructing the mother in palpation of bladder distention might not effectively address the issue of incomplete bladder emptying. Clean intermittent catheterization is a more appropriate technique to ensure complete emptying.

Choice B rationale:

Informing the mother that life-long antibiotic administration will be necessary is not the primary approach. Antibiotics may be required in specific situations, but addressing incomplete emptying is the key focus.

Choice C rationale:

Preparing the mother for the need for urinary diversion surgery is premature. Clean intermittent catheterization is a conservative measure that should be attempted before considering surgical options.

Choice D rationale:

Instructing the mother in the technique of clean intermittent catheterization helps manage the neurogenic bladder's incomplete emptying. This technique reduces the risk of urinary tract infections and promotes bladder health.

A. The patient will maintain a moist oral mucosa. B. The patient will increase physical mobility. C. The patient will remain free of infection. D. The patient will ingest a moderate potassium diet.

Correct Answer is C

Explanation

Choice A rationale:

While maintaining a moist oral mucosa is important, preventing infection takes precedence, as infections can lead to serious complications and compromise overall health.

Choice B rationale:

Increasing physical mobility is a valid goal, but infection prevention is more critical, especially when starting prednisone therapy, which can weaken the immune response.

Choice C rationale:

The priority lies in keeping the patient free of infection. Prednisone can suppress the immune system, making the patient more susceptible to infections that can have severe consequences.

Choice D rationale:

Ingesting a moderate potassium diet is important, but the prevention of infection takes precedence due to the potential for serious health risks associated with compromised immunity.

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A 14-year-old patient is brought unconscious to the emergency room. It is suspected that the patient has deliberately taken an overdose of acetaminophen with 1/2 pint of vodka. The healthcare provider prescribes several interventions. Which intervention should the nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has a neurogenic bladder with incomplete emptying. Which discharge instruction for the patient's mother should be included in the teaching plan?

Correct Answer is D

Explanation

A patient is started on prednisone therapy. Which of these goals should be given priority in the patient's plan of care?

Correct Answer is C

Explanation

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