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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Findings Consistent with Chorioamnionitis:
- Purulent amniotic fluid
- Fever
Findings Consistent with Preeclampsia:
- Elevated uric acid level
- Decreased platelet count
- Blurred vision
Rationale:
- Purulent amniotic fluid (Chorioamnionitis): Chorioamnionitis is an intra-amniotic infection, often leading to foul-smelling, purulent, or discolored amniotic fluid.
- Fever (Chorioamnionitis): Maternal fever is a hallmark sign of chorioamnionitis, indicating infection.
- Elevated uric acid level (Preeclampsia): Uric acid elevation is associated with endothelial dysfunction and reduced renal clearance seen in preeclampsia.
- Decreased platelet count (Preeclampsia): Thrombocytopenia can occur due to platelet consumption in severe preeclampsia or HELLP syndrome.
- Blurred vision (Preeclampsia): Visual disturbances occur due to cerebral edema and vasospasms, common in preeclampsia.
Correct Answer is A
Explanation
A. Keeping the umbilical cord area clean and dry helps prevent infection. Washing the base of the cord with water is recommended, while avoiding full immersion in water until the cord falls off.
B. The diaper should be folded down below the cord to prevent moisture buildup and irritation. Covering it can trap moisture and increase the risk of infection.
C. Minor bleeding is not expected when the stump falls off. Persistent or excessive bleeding should be reported to the provider.
D. Petroleum jelly is not recommended for umbilical cord care. The cord should be kept dry to facilitate natural detachment.
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