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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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 D
Explanation
A. "Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.
B. "Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.
C. "Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.
D. "Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.
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