A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
Start oxygen using a non-rebreather mask,
Have the patient drink large amounts of water.
Give N-acetylcysteine.
Discuss the use of chelation therapy.
The Correct Answer is C
A. Oxygen administration is not indicated for acetaminophen overdose unless respiratory distress is present.
B. Drinking water does not address acetaminophen overdose and its potential liver toxicity.
C. N-acetylcysteine is the antidote for acetaminophen overdose and should be administered to prevent liver damage.
D. Chelation therapy is not used in the treatment of acetaminophen overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates worsening in the client's condition since they are prone to infections.
B. In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C. In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D. In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E. The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.
Correct Answer is B
Explanation
A. Preparing a 60-mL syringe with saline may be necessary for gastric lavage but is not the first action.
B. For an unconscious patient who has ingested a significant quantity of lorazepam, securing the airway is the most critical first step to prevent aspiration and ensure the patient can breathe. Therefore, the nurse should assist with intubation of the patient.
C. The initial step is to ensure that the client’s airway is secured through intubation before administration of activated charcoal.
D. Inserting a large-bore orogastric tube may be necessary for gastric lavage but typically follows administration of activated charcoal.
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