NCLEX book The Unconscious Client
3. activated charcoal powder
88. A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in the car, and a drug overdose is suspected. Which medication should the nurse have available for further emergency treatment? 1. vitamin K 2. dextrose 50% 3. activated charcoal powder 4. sodium thiosulfate
3. Encourage the wife to express her feelings and concerns, and listen carefully.
90. The nurse is caring for a client who is unconscious following an attempted suicide by drug overdose. When speaking with the client's distraught wife, what should the nurse do first? 1. Explain that because the client was found on hospital property, he was probably asking for help and did not intentionally overdose. 2. Ask the wife if she would like to speak to a member of the clergy. 3. Encourage the wife to express her feelings and concerns, and listen carefully. 4. Allow the wife to help care for the client by rubbing his back when he is turned.
3. Maintain intact skin.
91. Which nursing action is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose? 1. Educate regarding drug abuse. 2. Minimize pain. 3. Maintain intact skin. 4. Increase caloric intake.
2. clean the mouth carefully, apply a thin coat of a water based lubricant, and move the endotracheal tube to the opposite side daily.
92. The nurse is caring for an unconscious intubated client with normal intracranial pressure. The nurse should: 1. monitor the oral temperature, keep the room temperature at 70° F (21.1° C), and place the client on a cooling blanket if the client's temperature is higher than 101°F (38.3° C). 2. clean the mouth carefully, apply a thin coat of a water based lubricant, and move the endotracheal tube to the opposite side daily 3. Position the client in the supine position with the head to the side and slightly elevated on two pillows. 4. turn the client with a drawsheet, and place a pillow behind the back and one between the legs.
3. The left arm is rested on the mattress with the elbow flexed.
93. The unconscious client is to be placed in a right side-lying position. The nurse should intervene when observing a client in which position? 1. The head is placed on a small pillow. 2. The right leg is extended without pillow support. 3. The left arm is rested on the mattress with the elbow flexed. 4. The left leg is supported on a pillow with the knee flexed.
1. Keep a suction machine available.
95. When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority? 1. Keep a suction machine available. 2. Place the client in a prone position. 3. Wear sterile gloves while brushing the client's teeth. 4. Use gauze wrapped around the fingers to clean the client's gums.
2. Lightly tape the eyelid shut.
96. The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? 1. Have the client wear eyeglasses at all times. 2. Lightly tape the eyelid shut. 3. Instill artificial tears once every shift 4. Clean the eyelid with a washcloth every shift.
3. restlessness
97. Which sign is an early indicator of hypoxia in the unconscious client? 1. cyanosis 2. decreased respirations 3. restlessness 4. hypotension
