The home health nurse enters the home of a client, and the client's spouse immediately reports that the client cannot be awakened and appears to have taken an overdose of some medications. After determining that the client is unresponsive but is breathing and has a pulse, which action should the nurse take?
Call 911 for emergency transport.
Determine what medications were ingested.
Contact the poison control center.
Attempt to induce vomiting using a tongue blade.
The Correct Answer is A
A) Call 911 for emergency transport:
The client is unresponsive, which is a critical situation requiring immediate medical attention. Even though the client is breathing and has a pulse, the unresponsiveness suggests a potentially severe overdose that could rapidly deteriorate. Calling 911 ensures that emergency medical services are on their way to provide advanced care and transport to a facility where further treatment can be administered.
B) Determine what medications were ingested:
While knowing what medications were taken is important for treatment, the immediate priority is to address the client’s unresponsiveness. Identifying the medications can be done once the client is stabilized or while awaiting emergency services, but it does not replace the need for urgent medical intervention.
C) Contact the poison control center:
Contacting the poison control center is useful for guidance on managing an overdose, but it should be done in conjunction with calling 911 if the client is unresponsive. The poison control center can provide specific treatment advice, but immediate emergency medical assistance is crucial for the client’s safety.
D) Attempt to induce vomiting using a tongue blade:
Inducing vomiting can be dangerous, especially if the client is unresponsive or has an impaired airway. Attempting to induce vomiting without professional medical support could lead to aspiration or other complications. The priority is to ensure the client receives proper medical care through emergency services.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Provide rehabilitation services to injured farm hands:
Providing rehabilitation services is important for recovery and improving the quality of life for those who have been injured, but it addresses the consequences of injuries rather than the prevention of injuries. This action focuses on managing the outcome of injuries rather than addressing the prevention of the agent causing the injuries.
B) Work with legislators to mandate safe tractor design:
Focusing on the agent in the epidemiological triad involves addressing the factors directly responsible for causing the injury. Working with legislators to mandate safe tractor design targets the agent (the tractor and its design) to prevent injuries. By ensuring that farm machinery is designed with safety features, the risk of injury is reduced, effectively addressing the source of the problem.
C) Teach farm workers not to smoke around farm equipment:
While teaching farm workers not to smoke around farm equipment is a valuable safety measure, it addresses a risk behavior related to fire hazards rather than the machinery itself. This action focuses on modifying behaviors rather than altering the agent of injury, which is the machinery.
D) Translate written vehicle instructions into picture format:
Translating instructions into picture format can improve understanding and safety by making instructions more accessible. However, this action primarily addresses the communication of safety procedures rather than changing or improving the agent causing the injuries. Focusing on the agent involves modifying the machinery itself rather than just improving instructions.
Correct Answer is C
Explanation
A) A young person with diabetes mellitus:
While diabetes mellitus is a significant health condition that requires management, especially in cold weather, it does not necessarily indicate an immediate or heightened risk compared to other conditions. Diabetes requires proper care and monitoring, but the urgency related to exposure to freezing temperatures may not be as critical as other conditions.
B) A middle-aged person who has hypertension:
Hypertension is an important condition that requires management, but in the context of a cold weather emergency, it does not represent an immediate risk related to exposure. The middle-aged person with hypertension may need stable conditions for managing their health, but their situation is less critical in terms of immediate exposure to freezing temperatures.
C) An older person who is malnourished:
An older person who is malnourished is at a higher risk when exposed to freezing temperatures. Malnutrition can impair the body’s ability to regulate temperature and increase susceptibility to cold-related illnesses such as hypothermia. Therefore, this individual is at greater risk and most in need of shelter to protect against the dangers of extreme cold.
D) An adult who was hit by a car 3 weeks ago:
An individual who was injured in a car accident 3 weeks ago may have ongoing medical needs, but unless there are specific complications or issues directly related to cold exposure, their immediate need for shelter due to freezing temperatures is less critical compared to a malnourished older person. Ensuring warmth and protection from the cold is the primary concern for those most vulnerable to the weather conditions.
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