A nurse in an emergency department is caring for a child who weighs 18 kg (39.7 lb) and ingested six 500 mg acetaminophen tablets 4 hr ago. Which of the following actions should the nurse take?
Send the child home on increased fluid intake.
Begin hemodialysis within the next 24 hr.
Perform gastric lavage with activated charcoal.
Prepare to give oral N-acetylcysteine.
The Correct Answer is D
A. Send the child home on increased fluid intake: Simply encouraging fluids is inappropriate in this case. The child has ingested a potentially toxic dose of acetaminophen, and delayed treatment can result in serious liver damage. Medical intervention is necessary.
B. Begin hemodialysis within the next 24 hr: Hemodialysis is not the first-line treatment for acetaminophen overdose. It may be used in rare, severe cases of liver failure or extremely high serum levels, but oral N-acetylcysteine is the standard antidote.
C. Perform gastric lavage with activated charcoal: Gastric lavage is typically effective only within 1 hour of ingestion. Since this ingestion occurred 4 hours ago, lavage is unlikely to be beneficial. Activated charcoal may still have some role, but it’s not the primary action at this point.
D. Prepare to give oral N-acetylcysteine: This is the antidote for acetaminophen toxicity and is most effective when given within 8 hours of ingestion. The child ingested 3,000 mg which exceeds the toxic dose threshold for a child weighing 18 kg. Prompt administration of N-acetylcysteine is critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
- Seizures: Bacterial meningitis causes inflammation and irritation of the brain's meninges, increasing the risk of seizures as the brain becomes more excitable. Seizures are a common serious complication and require close monitoring and prompt treatment.
- Increased intracranial pressure: Inflammation from meningitis can cause cerebral edema, leading to increased intracranial pressure (ICP). Elevated ICP can worsen neurological status and cause brain herniation if untreated, making it a critical complication to watch for.
Rationale for Incorrect Choices:
- Hypothermia: This child presents with fever Temperature 38.7° C (101.7° F), which is typical in bacterial meningitis; hypothermia is not a common risk in this condition.
- Disseminated intravascular coagulation (DIC): Although DIC can occur in severe sepsis, it is less common early in meningitis and not the greatest immediate risk. Additionaly the child has a normal platelet count 350,000/mm³ making DIC unlikely currently.
- Hydrocephalus: Hydrocephalus can develop as a late complication due to blockage of cerebrospinal fluid flow but is less immediate than seizures and increased ICP.
Correct Answer is C
Explanation
A. "Your child will need to receive sedation to minimize pain during the test.": Sedation is not necessary for a sweat chloride test. The test is noninvasive and painless, involving stimulation of sweat glands using a mild electric current.
B. "It will take approximately 3 hours to complete the test.": The entire sweat chloride test usually takes about 1 hour or less, including preparation and collection time. It is a quick procedure, not lasting multiple hours.
C. "Two separate samples will be collected to ensure accuracy of the test results.": Collecting two samples helps confirm the diagnosis, as elevated sweat chloride levels in both are indicative of cystic fibrosis. Repeat testing improves diagnostic reliability.
D. "Your child should avoid eating and drinking 6 hours prior to the test.": Fasting is not required for a sweat chloride test. The child can eat and drink normally before the procedure, as it does not affect the results.
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