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) Weight and height:
While measuring weight and height is important for assessing growth and overall health, it may not address the most critical health issues or concerns for high school students in the context of a health fair. Weight and height provide general health information but may not reflect more immediate or significant health needs specific to this population.
B) Sexual activity:
Assessing sexual activity is crucial in a health fair setting for high school students, as it directly relates to important health issues such as sexual health, risk of sexually transmitted infections (STIs), and unintended pregnancies. Understanding students’ sexual activity can help tailor educational programs and provide necessary resources and counseling, making it a priority assessment for addressing relevant health concerns.
C) Immunization history:
Immunization history is important for identifying gaps in vaccinations and ensuring that students are protected against preventable diseases. However, while relevant, it may not address the specific behavioral and health education needs that can be more directly assessed through discussions about sexual activity and associated risks.
D) Visual acuity:
Assessing visual acuity is important for identifying potential vision problems but may not address the broader range of health issues and behavioral concerns that are relevant for high school students. Visual acuity is one aspect of health but does not capture the comprehensive needs that can be identified through an assessment of sexual activity.
Correct Answer is B
Explanation
A) 80% of the students attend a voluntary sex education seminar:
While a high attendance rate at a sex education seminar indicates interest and participation in the program, it does not directly measure the program's impact on preventing student pregnancy. Attendance alone does not provide evidence of behavioral change or reduced pregnancy rates among students.
B) Students report an average delay of 2 years for their first sexual experience:
An average delay in the age of first sexual experience is a strong indicator of the program's effectiveness in influencing behavior. Delaying sexual activity can reduce the risk of unintended pregnancies, showing that the program has successfully impacted students' decisions regarding sexual activity.
C) Students requesting information about adolescent pregnancy has increased by 25%:
An increase in requests for information about adolescent pregnancy may suggest growing awareness or curiosity, but it does not directly measure changes in pregnancy rates or the effectiveness of the prevention program in reducing pregnancies.
D) 75% of the parents agree to support a pregnancy prevention program in the schools:
While parental support is important for the success of health programs, this measure reflects support and approval rather than direct outcomes related to pregnancy prevention. The effectiveness of the program is better gauged by changes in student behavior and pregnancy rates, rather than parental agreement.
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