The police bring a client to the emergency department to be examined after an automobile accident
He is ataxic, has slurred speech, and seems mildly confused. His blood alcohol level is 400 mg/dL
(0.40 mg%).
From the relation between his behavior and his blood alcohol level, the nurse can make
the assessment that the client
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has ingested both alcohol and sedative drugs recently.
B
A nontolerant drinker would be in coma with a blood alcohol level of 400 mg/dL (0.40 mg%). The
fact that the client is walking and talking shows a discrepancy between blood alcohol level and
expected behavior and strongly suggests that the client's body has become tolerant to the drug.
Option C: If disulfiram and alcohol are ingested together, an entirely different clinical picture would
result. Option D: The blood alcohol level gives no information about ingestion of other drugs.
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A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.
A patient with anorexia nervosa requires parenteral nutrition support. This patient demonstrates signs of marasmus. What intervention should the nurse make to prevent a complication for which this patient is at increased risk?
A) Limiting of initial dextrose dosing B) Depletion of potassium before TPN initiation C) Proper hand hygiene D) Change of TPN solution bag every 24 hours
You note that Unit 64 has had a high turnover rate of staff during the past year. In selecting the appropriate action, it is important that:
a. All documentation is reviewed. b. Usual processes for discipline are fol-lowed. c. Confidentiality is assured. d. An incident report is filed.
The heart rate of a newborn infant should be determined by:
A. auscultation of the apical pulse. B. gentle palpation of the carotid artery. C. auscultation of the carotid artery. D. palpation of the radial artery.