Question

The nurse is supervising care of a graduate nurse performing gastric lavage on a client with Acetaminophen overdose. The nurse should intervene if which action is observed?

1) Iced solution is instilled to promote vasoconstriction
2) Changes in VS and LOC are monitored
3) The client is placed in side-lying Trendelenburg
4) D. A large bore (38 F) tube is inserted for instillation of lavage fluid

Answer 1

The nurse should intervene if the graduate nurse places the client in a side-lying Trendelenburg position during a gastric lavage for an Acetaminophen overdose because it increases the risk of aspiration.

Step-by-step explanation:

The nurse should intervene if the graduate nurse places the client in a side-lying Trendelenburg position for gastric lavage in the case of an Acetaminophen overdose. This position could increase the risk of aspiration, which is especially hazardous in someone whose gag reflex may be compromised. Instead, the patient should be placed in a position that minimizes the risk of aspirating the lavage fluid, which is often a left lateral or semi-prone position with the head of the bed elevated.

Using iced solutions to promote vasoconstriction (1) can help to slow the absorption of the acetaminophen from the stomach. Monitoring for changes in vital signs (VS) and level of consciousness (LOC) (2) is a critical component of any detoxification process to detect early signs of deterioration. Inserting a large bore tube (38 F) (4) is acceptable for the instillation of lavage fluid, as it allows for efficient irrigation and rapid removal of stomach contents in an overdose situation.