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 increase my intake of vitamin D.": People with cystic fibrosis have fat malabsorption, which affects absorption of fat-soluble vitamins like A, D, E, and K. Supplementing vitamin D is essential to support bone health and prevent deficiencies.
B. "I will limit my calcium intake to prevent kidney stones.": Limiting calcium is not recommended. In fact, individuals with cystic fibrosis are at risk for low bone mineral density and need adequate calcium intake along with vitamin D to support bone development and prevent osteoporosis.
C. "I will be excused from physical education class.": Physical activity is encouraged in individuals with cystic fibrosis. It helps improve lung function, clear mucus from the airways, and maintain overall physical health. Avoiding PE would be counterproductive.
D. "I will take fewer enzymes when I eat high-fat foods.": High-fat foods require more pancreatic enzyme replacement to aid digestion and absorption. Taking fewer enzymes would result in malabsorption and GI symptoms.
Correct Answer is A
Explanation
A. Offer 1 tablespoon as a serving size for the infant's solid food: A typical serving size for solid foods when starting infants around 4 to 6 months is about 1 tablespoon per feeding, which helps avoid overfeeding and allows gradual introduction of solids.
B. Introduce solid foods when the infant reaches 3 months of age: Introducing solids before 6 months is not recommended due to immature digestive systems and increased risk of choking and allergies.
C. Add 1 teaspoon of honey to the infant's bottle of formula if constipation occurs: Honey should never be given to infants under 1 year old due to the risk of infant botulism, a serious and potentially fatal illness.
D. Introduce the infant to a new solid food every other day: Current recommendations suggest introducing one new food every 4 to 7 days to monitor for any allergic reactions or intolerance.
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