A nurse is caring for a client who has ingested a toxic agent.
Which of the following actions should the nurse plan to take?
Perform a mouth sweep.
Induce vomiting.
Instill activated charcoal.
Administer syrup of ipecac.
The Correct Answer is C
Choice A rationale
Performing a mouth sweep is not a recommended action for a client who has ingested a toxic agent. This procedure is typically used for unconscious individuals to clear the airway of solid objects and prevent aspiration. In the context of a toxic ingestion, a mouth sweep would be ineffective and potentially dangerous, as it could push the toxic substance further down the pharynx or cause injury. The primary focus for this type of emergency is to manage the ingested substance directly, not to clear the mouth of solid particles.
Choice B rationale
Inducing vomiting is no longer a recommended first-aid intervention for most poisonings. This practice can be harmful, as it risks aspiration of the toxic substance into the lungs, which could cause chemical pneumonitis or other severe respiratory damage. Furthermore, certain caustic or corrosive agents can cause more damage to the esophagus upon re-exposure during vomiting. Current guidelines from poison control centers and emergency medical services generally advise against inducing vomiting and instead recommend contacting a poison control center immediately for expert guidance.
Choice C rationale
Instilling activated charcoal is the most common and effective intervention for many types of toxic ingestions. Activated charcoal works by a process called adsorption, where the toxic substance binds to the surface of the charcoal particles, preventing its absorption into the bloodstream. This significantly reduces the systemic effects of the poison. It is typically administered orally or via a nasogastric tube within one hour of ingestion to maximize its binding capacity and effectiveness. The dosage and administration must be carefully considered based on the type of toxin and client's condition.
Choice D rationale
Administering syrup of ipecac is not a current recommended treatment for toxic ingestion. This substance, once used to induce vomiting, has been largely discontinued due to its limited effectiveness and potential for significant adverse effects, including lethargy and aspiration pneumonia. The risks associated with its use far outweigh any potential benefits, and its use is now considered contraindicated by most medical authorities. Its role has been replaced by more modern and safer methods of gastric decontamination, such as activated charcoal. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Atropine is an anticholinergic medication that is used to increase heart rate in bradycardia, not to speed up respirations. It works by blocking the vagus nerve's action on the heart. Administering atropine to a hypothermic patient with slow breathing is inappropriate and could have adverse effects without addressing the underlying hypothermia. The standard of care focuses on rewarming the patient.
Choice B rationale
Heparin is an anticoagulant used to prevent blood clot formation. It has no role in the management of hypothermia or slow breathing. Administering heparin would be an incorrect intervention and could put the client at risk of bleeding, especially if they have other injuries. The primary goal is to rewarm the client.
Choice C rationale
Removing wet clothing is a critical first step as wetness increases heat loss through evaporation. Applying warm blankets, or using other rewarming methods, is the primary treatment for hypothermia to restore the client's core body temperature and improve physiological function, including respiratory rate.
Choice D rationale
Trying to maintain a normal room temperature is an insufficient measure for a hypothermic client. The client's core body temperature is already below normal (less than 95°F or 35°C), and they require active rewarming techniques to raise it. Simply maintaining the room temperature will not be effective and will delay proper treatment. .
Correct Answer is D
Explanation
Choice A rationale
Providing equal care to all patients is a fundamental principle of routine emergency department triage, where resources are generally sufficient to provide a high standard of care to everyone. This approach is not feasible in a mass-casualty event, where limited resources and overwhelming patient numbers necessitate a different approach to maximize the number of survivors.
Choice B rationale
Prioritizing care based on arrival time is a common practice in routine triage for non-critical cases, ensuring fairness in the queue. However, in mass-casualty incidents, this method would be detrimental, as the most critical patients needing immediate intervention might be delayed, leading to a higher mortality rate and inefficient use of resources.
Choice C rationale
Prioritizing comfort measures for all patients is an ethical consideration in routine care, particularly for palliative or chronic conditions. In a mass-casualty event, this is impractical, as the primary objective shifts to life-saving interventions for the largest number of salvageable patients, often at the expense of non-critical care.
Choice D rationale
Mass-casualty triage, unlike routine triage, focuses on maximizing survival for the greatest number of people by allocating limited resources (personnel, equipment, and time) to those with the highest probability of survival. This utilitarian approach, often guided by systems like START triage, differs from the individual-focused care typical of routine emergency medicine.
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