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?
Perform gastric lavage with activated charcoal.
Begin hemodialysis within the next 24 hr.
Prepare to give oral N-acetylcysteine.
Send the child home on increased fluid intake.
The Correct Answer is C
A. Perform gastric lavage with activated charcoal. Activated charcoal is most effective if given within 1 hour of ingestion. Since the ingestion occurred 4 hours ago, activated charcoal would not be beneficial.
B. Begin hemodialysis within the next 24 hr. Hemodialysis is only used in severe cases of acetaminophen toxicity with liver failure, which is not indicated at this stage.
C. Prepare to give oral N-acetylcysteine. N-acetylcysteine (NAC) is the antidote for acetaminophen overdose and should be administered as soon as possible within 8 to 10 hours after ingestion to prevent liver damage.
D. Send the child home on increased fluid intake. Acetaminophen overdose can cause severe liver toxicity, so treatment in a medical setting is required, not just increased fluids at home.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"B"}}
Explanation
Bacterial Meningitis (Most Likely Diagnosis). Headache, nausea, irritability, lethargy, nuchal rigidity → Signs of meningeal irritation Petechiae → Possible meningococcal sepsis. Fever, chills, elevated WBC count (14,000/mm³) → Indicates an infection. Irregular respirations, agitation, capillary refill 4 seconds → Signs of worsening perfusion, possible sepsis
Hodgkin Lymphoma (Possible but Less Likely). Enlarged lymph nodes → Common in lymphoma but does not explain acute symptoms like fever, petechiae, or neurologic signs.
Acute Lymphoblastic Leukemia (ALL) (Possible but Less Likely). Petechiae → Possible due to thrombocytopenia, but child’s platelet count (350,000) is normal.. Enlarged lymph nodes → Can occur in leukemia but is not the primary concern given the acute symptoms.
Correct Answer is A
Explanation
A. "Two separate samples will be collected to ensure accuracy of the test results." For accuracy, the sweat chloride test is typically done with two separate samples to confirm the diagnosis of cystic fibrosis. The results are compared to ensure consistency.
B. "It will take approximately 3 hours to complete the test." The sweat chloride test typically takes around 30 to 60 minutes, not 3 hours. The process of stimulating sweat production and collecting it is usually brief.
C. "Your child will need to receive sedation to minimize pain during the test." The sweat chloride test is non-invasive and does not require sedation. It involves the application of a sweat-stimulating chemical, and the child may feel mild discomfort but does not require sedation.
D. "Your child should avoid eating and drinking 6 hours prior to the test." There are no specific fasting requirements before a sweat chloride test, although the child may be asked to stay well-hydrated to help produce sweat during the test.
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