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.

Answer and Explanation

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.

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Correct Answer is []

Explanation

Potential Condition:

Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.

Actions to Take:

Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.

Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.

Parameters to Monitor:

Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.

Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.

A. Remove both of the elastic bandages from the leg B. Obtain a prescription for pain medication. C. Discharge the client. D. Obtain a prescription for the appropriate anti-venom.

Correct Answer is D

Explanation

A. Removing the elastic bandages could lead to rapid systemic absorption of venom, increasing the severity of envenomation.
B. Pain management is important but secondary to administering anti-venom in cases of snakebite.
C. Discharging the client without proper evaluation and treatment for potential envenomation could lead to serious complications.
D. Administering the appropriate anti-venom is critical to neutralize venom effects and prevent worsening of symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse expect for this patient?

The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?

A nurse is reviewing the laboratory results of a client who was admitted with a history of multiple myeloma. The nurse should expect to find an increase in which of the following laboratory values?

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