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?
Prepare a 60-mL syringe with saline.
Assist with intubation of the patient.
Give first dose of activated charcoal.
Insert a large-bore orogastric tube.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["21"]
Explanation
Total volume in mL: 3000 mL
Time in hours: 24 hours
Total volume to be infused in minutes: We need to convert hours to minutes. There are 60 minutes in 1 hour. Therefore, total time in minutes = 24 hours * 60 minutes/hour = 1440 minutes
Drop factor: 10 gtt/mL
Rate in mL/min: We can divide the total volume (mL) by the total time (minutes) to find the flow rate in mL per minute. Rate (mL/min) = 3000 mL / 1440 minutes = 2.08 mL/min (rounded to two decimal places)
Rate in gtt/min: To find the rate in gtt/min, multiply the rate in mL/min by the drop factor. Rate (gtt/min) = 2.08 mL/min * 10 gtt/mL = 20.8 gtt/min
Rounding the answer to the nearest whole number: 20.8 gtt/min rounds off to the nearest whole number to 21 gtt/min.
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