Which nursing action is the most appropriate?

Posted by: Pdfprep Category: NCLEX-RN Tags: , ,

A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom.

Which nursing action is the most appropriate?
A . Put in a nasogastric tube and lavage the child’s stomach.
B . Monitor muscular status.
C . Teach mother poison prevention techniques.
D . Place child on respiratory assistance.

Answer: A

Explanation:

(A) The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child’s unconscious state prohibits forced emesis.

(B) Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure.

(C) The mother’s anxiety is probably so high that preventive guidance will be ineffective.

(D) Respiratory assistance is not needed if the child’s respiratory function is unaltered.

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