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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Expiratory wheezing is characteristic of asthma exacerbation. It indicates airway constriction and narrowing, leading to difficulty in exhaling and resulting in a high-pitched sound during expiration.
Choice B rationale:
Inspiratory crackle is not typically associated with asthma. Crackles are often heard in conditions involving fluid-filled airways, such as pneumonia.
Choice C rationale:
Expiratory grunting is not a common finding in asthma. Grunting sounds may be present in infants with respiratory distress, indicating the difficulty they experience while exhaling.
Choice D rationale:
Inspiratory stridor is not a usual manifestation of asthma. Stridor is more commonly related to upper airway obstruction, often seen in croup or epiglottitis.
Correct Answer is B
Explanation
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
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