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:

High levels of structure will cause behavioral problems is incorrect. Structure and routine often provide a sense of security for children with autism and can help minimize behavioral challenges.

Choice B rationale:

Negative reinforcement works better than positive reinforcement is not accurate. Positive reinforcement is generally more effective in promoting desired behaviors in children with autism.

Choice C rationale:

Strict dietary modifications can sometimes cure autism is a misconception. While a balanced diet can positively impact overall health, there is no dietary cure for autism spectrum disorder.

Choice D rationale:

Level of functioning varies significantly among children with autism is crucial information for parents. Autism is a spectrum disorder, leading to a wide range of abilities and challenges. Tailoring interventions to the child's specific needs is important.

A. Pedal edema. B. Cardiac arrhythmias. C. Circumoral cyanosis. D. Infrequent voiding.

Correct Answer is B

Explanation

Choice A rationale:

Pedal edema is not indicative of digoxin toxicity. Digoxin toxicity primarily affects the heart's electrical activity and rhythm, not fluid accumulation in the extremities.

Choice B rationale:

Cardiac arrhythmias are a hallmark sign of digoxin toxicity. Digoxin can lead to various types of arrhythmias, such as atrial tachycardia, atrial fibrillation, and ventricular ectopy. This occurs due to the drug's effects on altering the electrical conduction in the heart.

Choice C rationale:

Circumoral cyanosis is not a typical sign of digoxin toxicity. This symptom might be seen in conditions like methemoglobinemia or respiratory distress, but it's not directly related to digoxin toxicity.

Choice D rationale:

Infrequent voiding is not a specific sign of digoxin toxicity. It could be related to various factors, such as fluid intake, renal function, or underlying medical conditions, but it's not a hallmark of digoxin toxicity.

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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

What information should a nurse plan to give the parents of a child recently diagnosed with autism spectrum disorder?

Correct Answer is D

Explanation

The nurse is caring for a pediatric patient receiving digoxin therapy. Which assessment finding would indicate digoxin toxicity?

Correct Answer is B

Explanation

A patient newly diagnosed with insulin-dependent diabetes mellitus comes to the clinic one month after diagnosis. The mother tells the nurse, "My child is getting better. The glucose levels are almost normal and my child requires less insulin.". What is the most appropriate response by the nurse?

The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

A mother visits her critically ill infant daily. Which comment most strongly suggests this mother is successfully progressing in attachment to her infant?

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Which statement made by the caregiver of a 2-year-old child who is scheduled to have a voiding cystourethrogram (VCUG) indicates a correct understanding of the procedure?

A nurse is caring for a 10-day-old infant with a congenital heart defect. Which physical finding during nursing assessment is consistent with the patient's condition?

An 8-year-old patient with status asthmaticus insists on sitting straight up in bed. Which action should the nurse take?

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