The client who is experiencing alcohol withdrawal has a temperature of 100.6 °F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?

Administer benzodiazepine as ordered.

Provide emotional support.

Encourage the client to rest.

Monitor for any further changes.

Answer and Explanation

The Correct Answer is A

A. Administer benzodiazepine as ordered: Benzodiazepines are the first-line treatment for alcohol withdrawal because they reduce central nervous system hyperexcitability, preventing seizures and delirium tremens. The client's elevated vital signs indicate severe withdrawal, requiring immediate pharmacologic intervention.
B. Provide emotional support: Emotional support is important, but in acute alcohol withdrawal with signs of autonomic hyperactivity, stabilizing the patient medically takes precedence over psychosocial interventions.
C. Encourage the client to rest: While rest may help reduce stimulation, it is not sufficient to control severe withdrawal symptoms. The client needs medication to prevent progression to life-threatening complications.
D. Monitor for any further changes: Ongoing monitoring is necessary, but immediate action is required first. Waiting without intervention in the face of escalating symptoms can lead to worsening instability, including seizures or hypertensive crisis.

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Correct Answer is D

Explanation

A. Encourage the client to practice deep breathing: Deep breathing may be helpful in correcting respiratory acidosis or alkalosis, but it is not needed when the pH is normal. The client’s acid-base balance does not require intervention at this time.
B. Call the health care provider with the report: A pH of 7.4 is within the normal range (7.35–7.45). Reporting a normal pH value in isolation is generally not necessary unless it's part of a trend or if the clinical picture suggests otherwise. The nurse should complete their assessment and consider all findings before contacting the provider.
C. Obtain an ECG: An ECG may be warranted if there are signs of electrolyte imbalances or cardiac symptoms. However, a normal pH level alone does not justify performing an ECG in the absence of additional findings.
D. Finish the head-to-toe assessment: With a normal pH level, the nurse should continue routine care, including completing the assessment. No urgent intervention is required, making this the most appropriate next step.

A. Notify the physician. B. Recheck the apical pulse in 30 minutes. C. Administer the digoxin. D. Hold the digoxin.

Correct Answer is C

Explanation

A. Notify the physician: There is no immediate need to notify the provider since the heart rate is above the standard threshold for withholding digoxin. Clinical parameters are still within safe limits for administration.
B. Recheck the apical pulse in 30 minutes: Rechecking later may delay necessary therapy without cause. The heart rate is currently adequate, and there is no indication of bradycardia or instability.
C. Administer the digoxin: Digoxin is generally held if the apical heart rate is below 60 beats/minute in adults. Since the pulse is 62 and the client’s baseline is slightly higher, it is safe to administer the medication while continuing to monitor for any signs of bradycardia.
D. Hold the digoxin: Holding the dose is unnecessary unless the heart rate falls below 60 or there are signs of toxicity. In this case, the current rate does not warrant withholding the drug.

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The client who is experiencing alcohol withdrawal has a temperature of 100.6 °F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate?

Correct Answer is D

Explanation

Before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72 beats/minute. Which is the best action for the nurse to take?

Correct Answer is C

Explanation

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