A nurse is caring for a client who is experiencing acute alcohol toxicity. Which of the following actions should the nurse include in the plan?

Administer a stimulant to the client.

Administer a diuretic to the client.

Measure the client's urine specific gravity.

Insert an NG tube for the client.

Answer and Explanation

The Correct Answer is C

A. Stimulants should not be administered to clients with acute alcohol toxicity, as they can increase agitation and cardiovascular stress.
B. Diuretics are not used for alcohol toxicity because they do not effectively eliminate alcohol and may contribute to dehydration.
C. Measuring urine specific gravity helps assess hydration status and kidney function, which can be affected by acute alcohol toxicity.
D. An NG tube is not routinely indicated unless the client is at risk for aspiration or requires gastric lavage due to severe intoxication.

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Correct Answer is C

Explanation

A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.

A. "The client received morphine around lunch." B. "The client had a lung biopsy 1 hour ago." C. "Vital signs were obtained every 4 hours." D. "The client's partner is at their bedside."

Correct Answer is B

Explanation

A. Stating that the client received morphine "around lunch" is too vague. The exact time, dose, and effect should be included for accurate pain management.
B. A lung biopsy is a significant procedure that requires close monitoring for complications such as pneumothorax or bleeding. The oncoming nurse must be aware to provide appropriate post-procedure care.
C. General information about vital signs being taken every 4 hours is routine and not critical for handoff unless there are abnormalities or changes.
D. The presence of the client’s partner is not essential clinical information unless it impacts care, such as decision-making or emotional support needs.

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A nurse is caring for a client who is experiencing acute alcohol toxicity. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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