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 A
Explanation
A. I will dress my baby in lightweight clothing to sleep: Dressing the infant in lightweight clothing helps prevent overheating, which is a known risk factor for sudden unexpected infant death syndrome (SUIDS). Keeping the baby at a comfortable temperature promotes safer sleep.
B. I will move my baby's stuffed animal to the corner of their crib while they sleep: Any soft objects, including stuffed animals, pillows, or loose bedding, should be removed completely from the sleep area to reduce the risk of suffocation and SUIDS.
C. I will lay my baby on their side to sleep for naps: The safest sleep position for infants is on their back; side-lying positions increase the risk of airway obstruction and sudden infant death syndrome.
D. I will have my baby sleep next to me in bed during the night: Bed-sharing increases the risk of accidental suffocation or overlay and is not recommended for infant sleep safety, especially in infants at risk for SUIDS.
Correct Answer is D
Explanation
A. Hematemesis: Vomiting blood is not a typical finding in celiac disease; it usually indicates gastrointestinal bleeding from other causes such as ulcers or esophageal varices. Celiac disease primarily affects nutrient absorption rather than causing direct bleeding.
B. Redcurrant, jelly-like stools: This type of stool is characteristic of intussusception, a condition where part of the intestine telescopes into itself causing obstruction and bleeding. It is unrelated to the malabsorption seen in celiac disease.
C. Increased hemoglobin level: Celiac disease commonly causes malabsorption leading to iron deficiency anemia, which results in decreased hemoglobin levels. An increased hemoglobin level would not be expected because nutrient deficiencies impair red blood cell production.
D. Pale, oily stools: Steatorrhea, characterized by pale, bulky, and oily stools, occurs due to fat malabsorption in celiac disease. This reflects damage to the intestinal villi by gluten, which impairs digestion and absorption of fats and other nutrients. It is one of the hallmark clinical features of celiac disease.
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