A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?
Padding side rails to prevent injury.
Applying a cooling blanket.
Administering an anticonvulsant.
Preparing for artificial ventilation.
The Correct Answer is D
While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.
B. Applying a cooling blanket.
While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.
C. Administering an anticonvulsant.
While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.
D. Preparing for artificial ventilation.
Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give the client a PRN sleeping medication:
Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed:
Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client:
Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
Correct Answer is ["24"]
Explanation
To calculate the mL/hr for the heparin infusion, you can use the formula:
mL/hr = (Total units required per hour) / (Units/mL in the solution)
Given:
Total units required per hour = 1,200 U/hr
Units/mL in the solution = 25,000 U / 500 mL = 50 U/mL
Plugging in the values:
mL/hr = (1,200 U/hr) / (50 U/mL)
mL/hr = 24 mL/hr (rounded to the nearest tenth)
Therefore, the nurse should set the IV pump to deliver 24 mL/hr for the heparin infusion.
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