A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

Do not take any over-the-counter medications.

Eat a high carbohydrate, low fat, low protein diet.

Call the crisis hot line if feeling lonely.

Avoid exposure to large crowds.

Answer and Explanation

The Correct Answer is A

A.   Do not take any over-the-counter medications. This is crucial because many over-the-counter medications, including those containing acetaminophen, can further damage the liver. Avoiding these medications is essential to prevent further hepatic injury.
B.   Eat a high carbohydrate, low fat, low protein diet. While diet can influence liver health, this specific dietary advice is less critical than preventing further liver damage from medications.
C.   Call the crisis hot line if feeling lonely. This is important for mental health support, but the immediate physical health concern related to liver damage takes precedence.
D.   Avoid exposure to large crowds. This may be relevant if the client is immunocompromised due to liver damage, but it is not as directly related to preventing further liver injury as avoiding certain medications.

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Correct Answer is C

Explanation

A. Explaining that temporary burning at the IV site may occur is important for informing the client about potential side effects but does not address the specific risk associated with vesicant chemotherapeutic agents.

B. Applying a topical anesthetic at the infusion site for burning is not typically indicated during the administration of vesicant chemotherapeutic agents. While it may provide some comfort, it does not address the risk of extravasation.

C. Assessing the IV site frequently for signs of extravasation is essential during the administration of vesicant chemotherapeutic agents. Vesicants can cause tissue necrosis and damage if they leak into surrounding tissues. Early detection of extravasation allows for prompt intervention to minimize tissue damage.

D. Monitoring capillary refill distal to the infusion site is important for assessing peripheral perfusion but does not specifically address the risk of extravasation associated with vesicant chemotherapeutic agents.

A. Administer oxygen 5 L/minute via simple face mask B. Bacitracin applied topically to lacerations every 12 hours C. Place 2 large bore peripheral IV's D. X-ray of the right arm and cervical spin E. Computed tomography scan of the brain F. Vital signs ever 1 hour G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once

Correct Answer is ["A","C","G"]

Explanation

A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.

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A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm?

Correct Answer is C

Explanation

Correct Answer is ["A","C","G"]

Explanation

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