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.
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Related Questions
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.
Correct Answer is D
Explanation
A. "You can take this medication with milk." This is incorrect because dairy products interfere with the absorption of tetracycline and should be avoided when taking the medication.
B. "You should take this medication at bedtime." This is incorrect because taking tetracycline at bedtime increases the risk of esophageal irritation. It should be taken with a full glass of water while sitting or standing upright.
C. "Constipation is an adverse effect of this medication." This is incorrect because tetracycline is more commonly associated with diarrhea rather than constipation.
D. "Light sensitivity is an adverse effect of this medication." This is correct because tetracycline can cause photosensitivity, making the skin more susceptible to sunburn. Clients should be advised to use sunscreen and wear protective clothing when exposed to sunlight.
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