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 C

Explanation

Choice A rationale:

Threat to body image is not the primary concern for an 8-year-old patient undergoing diagnostic testing for seizures. Seizures are primarily neurological in nature.

Choice B rationale:

Fear of bodily injury might be a concern, but for an 8-year-old patient undergoing diagnostic testing for seizures, the more immediate concern would likely be related to their social interactions and acceptance among peers.

Choice C rationale:

Loss of peer acceptance is the most likely psychological concern for an 8-year-old patient during diagnostic testing. Children at this age are highly conscious of fitting in with their peers, and a medical condition might make them worry about being different.

Choice D rationale:

Separation from parents could be a concern for younger children, but 8-year-olds are generally more independent and less likely to experience extreme separation anxiety.

A. Holds the child's head in an upright position during feeding. B. Places the tip of the syringe in the side of the child's mouth. C. Burps the child frequently during the feeding. D. Places the child in a prone position after feeding.

Correct Answer is D

Explanation

The correct answer is choice d. Places the child in a prone position after feeding.

Choice A rationale:

Holding the child’s head in an upright position during feeding is appropriate as it helps prevent aspiration and ensures proper swallowing.

Choice B rationale:

Placing the tip of the syringe in the side of the child’s mouth is correct because it helps direct the formula to the back of the mouth, reducing the risk of choking.

Choice C rationale:

Burping the child frequently during the feeding is necessary to release any swallowed air, which can help prevent discomfort and spitting up.

Choice D rationale:

Placing the child in a prone position after feeding is incorrect and indicates a need for further instructions. After feeding, the child should be placed in an upright or slightly elevated position to prevent aspiration and reduce the risk of gastroesophageal reflux.

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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

An 8-year-old patient suspected of having seizures is admitted to the hospital for a diagnostic workup. Which psychological concern is the patient most likely to have during diagnostic testing?

Correct Answer is C

Explanation

After a cleft lip repair, a child is receiving formula feedings through a syringe. The child's parent is participating in care. Which of these actions by the parent indicates a need for further instructions about feeding the child? The caregiver:.

Correct Answer is D

Explanation

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Which statement, if made by a caregiver of a 2-year-old child diagnosed with cerebral palsy requires further discussion?

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A nurse is caring for a 3-year-old patient. Which behavior is developmentally appropriate for this patient?

The nurse should evaluate that a teenager understands when to take prescribed pancreatic enzymes when the client makes which statement?

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