The nurse is caring for a client admitted to the hospital after an automobile accident who has a blood alcohol concentration (BAC) of 48 mmol/L (0.22 mg%). The client is alert and does not appear highly intoxicated. Which of the following nursing actionsshould the nurse implement?
A)Maintain the client on NPO status.
B)Avoid the use of intravenous (IV) fluids.
C)Administer acetaminophen for headache.
D)Monitor frequently for anxiety, hyper-reflexia, and sweating.

Question

Quizplus · Accepted Answer

The client's assessment data indicate physiological dependence on alcohol, and the client is likely to develop acute withdrawal such as anxiety, hyper-reflexia, and sweating, which could be life-threatening. Acetaminophen is not recommended because it is metabolized by the liver. IV thiamine and IV glucose solutions usually are given to intoxicated clients to prevent Wernicke's encephalopathy, and there is no indication that the client should be NPO.

The Nurse Is Caring for a Client Admitted to the Hospital