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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?

A.

WBC count

B.

Intake and output

C.

ABGs

D.

Blood glucose level

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

  • Place on a Low-protein diet: A low-protein diet is often prescribed in clients with hepatic encephalopathy to reduce ammonia production from protein metabolism. With an ammonia level of 150 mcg/dL and signs of chronic liver disease, this is appropriate.
  • Daily abdominal girth measurements: This client has a distended abdomen with dullness to percussion, suggesting ascites. Measuring abdominal girth daily helps monitor fluid accumulation and response to diuretics or fluid restriction.
  • Daily weights: Weight tracking is essential in clients with ascites or fluid imbalance, common in cirrhosis. It provides a sensitive indicator of fluid retention or loss over time.
  • Liver biopsy: With thrombocytopenia (platelets 120,000/mm³), active GI bleeding, and coagulopathy likely due to cirrhosis, liver biopsy poses a high bleeding risk and is not appropriate in this unstable condition.
  • Administer lactulose: Lactulose is a first-line treatment for hepatic encephalopathy. It works by trapping ammonia in the colon and promoting its excretion. This is essential given the client's elevated ammonia level and risk for mental status changes.
  • Liver ultrasound: A liver ultrasound is a non-invasive imaging tool to evaluate liver size, structure, and presence of masses or ascites. It is safe and appropriate in this client's condition and can guide further management.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

Rationale:

  • Troponin I level: An elevated troponin I level indicates myocardial cell injury and is a key diagnostic marker for MI. Even a value at the upper limit of normal (0.03 ng/mL) warrants concern, especially with accompanying symptoms.
  • ECG result – sinus tachycardia: Sinus tachycardia is nonspecific but may occur in both MI and angina due to pain, anxiety, or sympathetic stimulation. However, more definitive MI-related changes like ST elevation or Q waves would provide clearer diagnostic value.
  • Heart rate: A heart rate of 116/min is elevated and may represent the body’s response to pain, hypoxia, or stress. This can be seen in both angina and MI, though persistent or worsening tachycardia in MI may indicate hemodynamic instability.
  • Heart palpitations: Palpitations are common during episodes of angina and are often due to increased sympathetic tone or transient arrhythmias. They are usually mild and resolve with rest or nitroglycerin in stable angina.
  • Blood pressure: A blood pressure of 158/92 mm Hg indicates hypertension, a known trigger and risk factor for angina. Elevated BP increases myocardial oxygen demand, potentially precipitating chest pain in those with coronary artery disease.

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