Today’s NCLEX-RN® question of the day focuses on a nurse who is assessing a 4-year-old patient who ingested half a bottle of chewable acetaminophen and documenting the findings in the EHR, what specific findings should the nurse look for that correlate with poison exposure? Can you figure it out?
The nurse is caring for a 4-year-old patient who was brought to the emergency department (ED) after ingesting half a bottle of chewable acetaminophen. The nurse performs an initial assessment and documents the findings in the electronic health record (EHR).
Which finding(s) correlate(s) with poison exposure?
A.
| Electronic Health Record (EHR) | |
| Temperature | 98.6 F (37 C) Tympanic |
| Heart Rate | 110/min |
| Respirations | 22/min |
| Blood Pressure | 95/62 mmHg |
| Oxygen Saturation | 97% on room air |
| Pain | 4/10 Wong Baker Faces scale |
| General appearance | Emesis X1, sweating, pallor |
B.
| Electronic Health Record (EHR) | |
| Temperature | 98.6 (37.0 C) Tympanic |
| Pulse | 110/min |
| Respiration | 22/min |
| Blood Pressure | 95/62 mmHg |
| Oxygen Saturation | 97% room air |
| Pain | 4/10 Wong Baker Faces scale |
| General | Emesis X1, sweating, pallor |
Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
B.
| Electronic Health Record (EHR) | |
| Temperature | 98.6 (37.0 C) Tympanic |
| Pulse | 110/min |
| Respiration | 22/min |
| Blood Pressure | 95/62 mmHg |
| Oxygen Saturation | 97% room air |
| Pain | 4/10 Wong Baker Faces scale |
| General | Emesis X1, sweating, pallor |
Major Takeaway
The nurse should use clinical judgment to recognize cues related to poisoning by identifying relevant information gathered during the assessment. Early symptoms of acetaminophen toxicity include diaphoresis, pallor, nausea, vomiting, and abdominal pain. As the liver injury progresses, individuals may develop late symptoms associated with acute hepatic necrosis and liver failure. This can present with jaundice or yellowing of the skin, coagulopathy or impaired clot formation, and hepatic encephalopathy or brain dysfunction that’s due to liver disease. Normal vital signs for a 4-year-old child are temperature: under 100.4 F (38 C), heart rate 80 to 120/min, respiratory rate: 20 to 28/min, blood pressure: 89-112 mmHg systolic and diastolic 46-72 mmHg, and oxygen saturation 95 to 100% on room air.
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