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 A

Explanation

A. A bluish-white colored pupil. This is correct because cataracts cause clouding of the lens, leading to a grayish or bluish-white appearance of the pupil. This opacity gradually impairs vision.
B. Decrease in peripheral vision. This is incorrect because a loss of peripheral vision is characteristic of glaucoma, not cataracts.
C. Increased intraocular pressure. This is incorrect because increased intraocular pressure is a hallmark of glaucoma, not cataracts.
D. Loss of central vision. This is incorrect because central vision loss is associated with macular degeneration rather than cataracts.

A. Strain the client's urine. B. Limit each of the client's visitors to 2 hr per day. C. Attach a dosimeter to the client's gown. D. Instruct visitors to stay 1 m (3.3 feet) away from the client.

Correct Answer is D

Explanation

A. Strain the client's urine. This is incorrect because straining urine is necessary for clients with radioactive seeds placed in the bladder, but not for prostate cancer brachytherapy, where the seeds typically remain in place.
B. Limit each of the client's visitors to 2 hr per day. This is incorrect because visitors should be limited to short durations, but the exact time is typically restricted to 30 minutes per visit rather than a total of 2 hours per day.
C. Attach a dosimeter to the client's gown. This is incorrect because a dosimeter should be worn by healthcare staff, not attached to the client. It helps monitor radiation exposure for staff members.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client. This is correct because maintaining a safe distance from the client helps minimize radiation exposure for visitors. Visitors should also limit their time near the client and avoid close contact.

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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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