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Question 1 of 5

A 15-year-old client took a full bottle of extra-strength acetaminophen in a suicide attempt 5 hours prior to admission to the emergency department for treatment, and the serum level of the drug is 180 mcg/mL. Which of the following interventions does the nurse anticipate? Select all that apply.

Correct Answer: A,B,C,D,E

Rationale: Acetaminophen overdose requires NAC (
A), supportive care (
B), charcoal if within 4-8 hours (
C), hepatic monitoring (
D), and psychiatric consultation (E) for suicide attempt.

Question 2 of 5

Which client should be assigned to the nursing assistant?

Correct Answer: C

Rationale: The elderly client with a thyroidectomy 4 days ago is stable and suitable for routine care by a nursing assistant.

Question 3 of 5

A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

Correct Answer: C

Rationale: A goiter associated with hyperthyroidism may cause exophthalmos (bulging eyes) due to increased thyroid hormone levels.

Question 4 of 5

The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?

Correct Answer: D

Rationale: A cheese omelet is gluten-free, suitable for celiac disease, unlike the other options containing wheat.

Question 5 of 5

The nurse is caring for a client with chronic kidney failure who is receiving Epoetin alfa. The nurse understands which statement to be true regarding this medication?

Correct Answer: D

Rationale: Epoetin alfa stimulates red blood cell production and is typically given weekly via IM or subcutaneous routes. Other options misrepresent its effects or side effects.

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The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client's level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client?

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