Acetaminophen Poisoning 1.A nurse is completing an

Acetaminophen Poisoning 1.A nurse is completing an assessment of a child with a nasogastric tube prior to medication administration. While preparing the medication, the nurse notes that the tape securing the tube is loose and that the tube has moved about 6 cm. The nurse’s next intervention should be to: re-tape the tube and continue with medication administration. check the pH of the gastric contents by aspirating some from a syringe. prepare for reinsertion of the gastric tube. administer the medication orally instead, if the child is able to swallow. 2.Which signs and symptoms are most suggestive of liver involvement in a child with an acetaminophen overdose? Nausea and vomiting Sweating, pallor, and tachycardia Elevated PT and PTT and complaints of right upper quadrant pain An acetaminophen level of 18 mcg/mL 3.A 2-year-old toddler should be in which of Erickson’s developmental stages? Autonomy vs. shame and doubt Trust vs. mistrust Industry vs. accomplishment Sensorimotor vs. preoperational 4. Following reinsertion of the nasogastric tube, x-ray results indicate that the tip of the tube is located in the stomach. The nurse anticipates an order to: administer medications through the nasogastric tube. advance the nasogastric tube 1 cm. pull back the nasogastric tube 2 cm. discontinue the nasogastric tube and administer oral medications. 5.How often should the nurse assess a peripheral IV site infusing dextrose 5% in ½ normal saline with 2 mEq potassium chloride per 100 mL at 41 mL/hour? Once a shift Every 5 hours and PRN Every 15 minutes Every 1 hour 6.When preparing to discharge a toddler from the hospital after having an acetaminophen overdose, which statement from the mother would best indicate an understanding of the discharge instructions? “I have the poison control by my phone.” “My son can never take acetaminophen again.” “We have all the medications and other potentially hazardous substances locked in cupboards out of reach.” “He can’t drink anything for 24 hours following the removal of the tube from his stomach.” 7.A nurse notices that a toddler is jaundiced and is having right upper quadrant pain. The nurse should be concerned with: A low platelet count. Developing an overwhelming hospital-acquired infection. Acetaminophen ingestion is causing hepatic involvement. Kidneys are failing. 8.A nurse is reviewing a toddler’s laboratory results and sees that his initial acetaminophen level was 212 mcg/mL. This finding is consistent with: a toxic level of acetaminophen in the serum. a therapeutic level of acetaminophen in the serum. a high level of acetaminophen in the serum. a low level of acetaminophen in the serum. 9. A toddler has had an episode of emesis, has not had a wet diaper in 5 hours, and has a capillary refill greater than 3 seconds. Which intervention might the nurse anticipate the physician to order next? NPO status and encouraging fluids Increasing the maintenance fluid rate Administering a bolus of a crystalloid at 20 mL/kg Requesting a blood pressure assessment 10.Which number represents the daily maintenance fluid requirement for a 20-lb child? 909 mL 1000 mL 90 mL 800 mL

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