A nurse is assisting in the care of a client admitted for an acetaminophen overdose. Which of the following prescriptions should the nurse anticipate implementing?
Monitor amylase and lipase.
Give acetylcysteine.
Obtain a chest x-ray.
Administer naloxone
The Correct Answer is B
B. Acetylcysteine, also known as N-acetylcysteine (NAC), is the antidote for acetaminophen overdose. It works by replenishing depleted glutathione stores in the liver and preventing or reversing hepatotoxicity caused by acetaminophen overdose. Acetylcysteine should be administered as soon as possible after an acetaminophen overdose to maximize its effectiveness in preventing liver damage.
A. Monitoring amylase and lipase levels is not directly related to acetaminophen overdose. Amylase and lipase are pancreatic enzymes that are typically monitored to assess pancreatic function and diagnose conditions such as pancreatitis.
C. Obtaining a chest x-ray is not typically indicated for acetaminophen overdose. Acetaminophen overdose primarily affects the liver, and the manifestations are predominantly related to hepatotoxicity.
D. Naloxone is an opioid antagonist used to reverse opioid overdose by blocking opioid receptors. It is not indicated for acetaminophen overdose. Acetaminophen overdose does not involve opioid receptors, and naloxone would not be effective in treating acetaminophen toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Before administering any medication, the nurse should positively identify the client using at least two unique identifiers (e.g., name, date of birth, medical record number). Positive identification helps prevent medication errors and ensures that the medication is administered to the intended recipient.
A. Validating the prescription with the available medication is an important step to ensure that the correct medication is being administered. However, before doing so, it's essential to confirm the identity of the client and the correct time for administration.
B. Calculating the correct amount of medication is necessary to ensure that the client receives the appropriate dose. However, before performing this calculation, it's essential to confirm the identity of the client and the correct time for administration.
C. Documenting the time of medication administration is important for maintaining an accurate record of the client's medication administration history. However, before documenting, it's crucial to confirm the identity of the client and the correct time for administration.
Correct Answer is A
Explanation
A. Increased respiratory rate is a sign that naloxone is effectively reversing opioid-induced respiratory depression. Opioids can suppress the respiratory drive, leading to hypoventilation or respiratory arrest. Naloxone works by competitively binding to opioid receptors and displacing opioids, thereby restoring normal respiratory function.
B. Increased temperature is not a direct effect of naloxone administration. Naloxone primarily reverses the central nervous system depressant effects of opioids, including respiratory depression and sedation, rather than affecting body temperature.
C. Naloxone does not directly affect pain perception. Its primary action is to reverse the respiratory depression and central nervous system depression caused by opioids. While the client may experience pain relief indirectly as a result of improved respiratory function and consciousness, naloxone itself does not directly reduce pain.
D. Decreased blood pressure is not a direct effect of naloxone administration. Naloxone primarily reverses the respiratory and central nervous system depressant effects of opioids, rather than affecting blood pressure directly.
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