Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?
The patient frequently uses an alcohol-based sanitizer for hand hygiene.
The patient takes acetaminophen 1000 mg every 4 hours around the clock.
The patient takes alprazolam 0.25 mg every 8 hours.
The patient rinses with a fluoride mouthwash after brushing the teeth.
The Correct Answer is B
Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.
Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.
Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 8 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.
Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.
Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.
Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.
Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Wiping up the liquid with paper towels and gloves can spread the mercury droplets and increase the risk of exposure. Mercury can also penetrate through nitrile gloves and cause skin irritation.
Choice B reason: This is incorrect. Disinfecting the area with chlorine bleach can create toxic vapours that can harm the respiratory system. Chlorine bleach is not effective in removing mercury from the surface.
Choice C reason: This is incorrect. Contacting the housekeeping staff to mop up the liquid can delay the proper clean-up and disposal of mercury. Mopping can also disperse the mercury droplets and contaminate the mop and the water.
Choice D reason: This is correct. Consulting the agency’s materials safety data sheets (MSDS) is the priority action of the nurse. MSDS provide information on the hazards, precautions, and procedures for handling and disposing of mercury. The nurse should follow the MSDS guidelines and use the appropriate equipment and methods to clean up the spill.
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