A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?
WBC count
Intake and output
ABGs
Blood glucose level
The Correct Answer is C
Rationale:
A. WBC count: Monitoring the white blood cell count is useful for detecting infection, but heroin toxicity primarily affects the respiratory system. An elevated or normal WBC does not provide immediate information about the client's ventilation or gas exchange status.
B. Intake and output: Tracking fluid balance is important for overall patient monitoring, especially in critically ill clients. However, it does not provide direct insight into the effectiveness of mechanical ventilation or the client's oxygenation status.
C. ABGs: Arterial blood gases are the priority assessment because they directly measure the client's oxygenation, ventilation (CO₂ removal), and acid-base status. Since heroin toxicity can cause respiratory depression, ABGs are essential to evaluate the effectiveness of mechanical ventilation.
D. Blood glucose level: Although monitoring glucose is important in critically ill clients, heroin use is not typically associated with hypo- or hyperglycemia. Blood glucose assessment is not as urgent as evaluating respiratory function in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Cauliflower is a good dietary choice”. Cauliflower is a gas-forming vegetable that can increase abdominal discomfort in clients with gallbladder disease. It is not typically recommended during symptomatic periods or recovery from cholelithiasis.
B. "Increase the amount of egg yolks in your diet." Egg yolks are high in cholesterol and fat, which can trigger gallbladder contractions and worsen symptoms in clients with cholelithiasis. These should be limited or avoided.
C. "Select desserts such as angel-food cake." Angel-food cake is low in fat and cholesterol, making it an appropriate dessert option for individuals with gallbladder disease. Low-fat and non-irritating foods are key to managing symptoms.
D. "Eat choice or prime cuts of meat." Choice or prime cuts tend to have a higher fat content. High-fat meats can exacerbate symptoms by stimulating bile production and gallbladder contractions, which should be avoided in cholelithiasis.
Correct Answer is A
Explanation
Rationale:
A. "If my heart starts racing, my provider might need to adjust my dosage.": This statement shows understanding. Tachycardia is a common sign of overtreatment with levothyroxine, which may lead to hyperthyroidism. The provider should be notified to adjust the dosage if such symptoms occur.
B. "I will keep a journal of my daily food intake to show the provider.": While nutrition is important, this is not a routine requirement for levothyroxine management. The effectiveness of therapy is primarily monitored through thyroid function tests, not dietary logs.
C. "Once my weight is back to normal, I can gradually reduce and then stop the medication.": This indicates a misunderstanding. Levothyroxine is a lifelong therapy for most clients with hypothyroidism, and stopping it can lead to a return of symptoms and complications.
D. "I'm not forgetful, so I do not need a pill reminder system.": While this may be true for some, consistent daily dosing is critical with levothyroxine. Even clients with good memory may benefit from reminder systems to ensure adherence and maintain stable hormone levels.
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