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","C","D","F"]
Explanation
A. Capillary refill of 4 seconds is prolonged and indicates poor perfusion, which is a sign of worsening dehydration or possible shock. This requires immediate follow-up.
B. Hyperactive bowel sounds are expected in a toddler with diarrhea and do not indicate immediate deterioration.
C. Cool extremities suggest poor circulation and possible hypovolemia or shock, requiring urgent assessment.
D. Absence of tears is a classic sign of dehydration in a toddler and indicates worsening fluid deficit that needs prompt intervention.
E. Diaper area redness is common with diarrhea and indicates skin irritation, but it is not a priority compared to signs of dehydration or shock.
F. Lethargy is a concerning neurologic change and may indicate severe dehydration or decreased perfusion, requiring immediate attention.
G. Heart rate of 112/min is within expected range for a toddler and does not indicate acute deterioration.
H. Respiratory rate of 26/min is within normal limits for a toddler and is not a priority concern.
Correct Answer is ["A","B","C","G","H","I","J"]
Explanation
Rationale for Correct Answers:
- Mucous membranes pink and moist: Reflects adequate hydration and improved fluid status compared to previous "dry and sticky" description.
- Respirations are regular/ RR 24/min: Indicates stable respiratory function with no signs of distress or respiratory compromise as compared to the previous irregular respirations
- HR 104/min / BP 104/80 mm Hg: Demonstrates cardiovascular stability within age-appropriate ranges and an improvement from the initial readings
- Radial pulse 2+ bilateral / Cap refill < 2 seconds: Suggests good perfusion and improved circulatory status compared to previous delayed cap refill and weak pulses.
- SpO₂ 98% on room air: Demonstrates sufficient oxygenation without need for respiratory support and an improvement from 97%.
Rationale for Incorrect Choices:
- Drowsy and lethargic, but responsive to verbal stimuli: Neurologic status has not improved from the previous day; continued lethargy and altered mental status require ongoing evaluation.
- Nuchal rigidity present: This is a classic sign of meningeal irritation and ongoing central nervous system involvement; it has not resolved and remains concerning.
- Temperature 38.9°C (102°F): The elevated temperature indicates persistent fever, suggesting that the infection or inflammation is still active.
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