Nurse labs RN Test Bank 1 NCLEX solved

Nurse labs RN Test Bank 1 NCLEX Question Tag: acetaminophen Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first? A. Gastric lavage B. Administer acetylcysteine (Mucomyst) orally C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open D. Have the patient drink activated charcoal mixed with water Correct Answer: A. Gastric lavage Option A: Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as much of the drug as possible is the first step in treatment for acetaminophen overdose, this is best done through gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating the fluid back out. This procedure is done in life-threatening cases such as acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion. Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment of acetaminophen overdose but should be done after GI decontamination with activated charcoal. Liver damage is minimized by giving acetylcysteine (Mucomyst), the antidote for acetaminophen. Acetylcysteine reduces injury by substituting for depleted glutathione in the reaction that converts the toxic metabolite of acetaminophen to its nontoxic form. When given within 8 hours of acetaminophen toxicity, acetylcysteine is effective in preventing severe liver injury. It is administered orally or intravenously. Option C: Intermittent IV infusion with Dextrose 5% may be considered for late- presenting or chronic ingestion. Option D: Oral activated charcoal (AC) avidly adsorbs acetaminophen and may be administered if the patient presents within 1 hour after ingesting a potentially toxic dose. Charcoal should not be administered immediately before or with antidotes since it can effectively adsorb it and neutralize the benefits. NCLEXRN-01-003 Question Tag: cardiac catheterization Question Category: Safe and Effective Care Environment, Management of Care Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A. Angina at rest B. Thrombus formation C. Dizziness D. Falling blood pressure Correct Answer: B. Thrombus formation A thrombus formation may prevent blood from flowing normally through the circulatory system, which may become an embolism, and block the flow of blood towards major organs in the body. Option A: The reported incidence of myocardial infarction with angina at rest is less than 0.1%, and is mostly influenced by patient-related factors like the extent and severity of underlying cardiovascular-related diseases and technique-related factors. Options C & D: A falling BP and dizziness occur along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. NCLEXRN-01-004