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 B
Explanation
B. Hemoglobin levels should be monitored regularly to assess the effectiveness of epoetin alfa therapy. Epoetin alfa stimulates the production of red blood cells, which should result in an increase in hemoglobin levels over time in clients with anemia. Monitoring hemoglobin levels helps determine if the medication is achieving the desired therapeutic effect.
A. Thrombin time measures the time it takes for a clot to form in a blood sample after thrombin is added. It is primarily used to assess abnormalities in the conversion of fibrinogen to fibrin during the clotting process. Thrombin time is not typically monitored to assess the effectiveness of epoetin alfa.
C. AST is an enzyme found primarily in the liver and heart. Elevated AST levels may indicate liver or heart damage but are not specifically related to the effectiveness of epoetin alfa therapy. AST is not routinely monitored to assess the effectiveness of epoetin alfa.
D. Troponin is a cardiac biomarker used to diagnose myocardial infarction (heart attack). Elevated troponin levels indicate damage to the heart muscle. Troponin levels are not directly related to the effectiveness of epoetin alfa therapy and are not routinely monitored for this purpose.
Correct Answer is D
Explanation
D. Chills are a hallmark sign of febrile nonhemolytic reactions. These reactions typically present with fever, chills, and occasionally rigors (shivering). They are caused by recipient antibodies reacting to donor leukocytes or cytokines present in the transfused blood components.
A. Dyspnea (difficulty breathing) is not typically associated with febrile nonhemolytic reactions. It is more commonly seen in acute hemolytic reactions or transfusion-related acute lung injury (TRALI).
B. Urticaria (hives) is more commonly associated with allergic transfusion reactions rather than febrile nonhemolytic reactions.
C. Vomiting is not a characteristic feature of febrile nonhemolytic reactions. It may occur in some cases of transfusion reactions, but it is not specific to febrile nonhemolytic reactions.
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