# The 24-year-old client weighs 60 kg and ingested 30 immediate-release acetaminophen 500-mg tablets (15 g, 250 mg/kg) at 0100 and arrived at 0730. A timed 4-hour acetaminophen concentration drawn at 0500 at an urgent-care clinic before transfer was 185 mcg/mL. AST is 24 U/L, ALT 21 U/L, INR 1.0, and creatinine 0.8 mg/dL. The client reports nausea and mild right-upper-quadrant discomfort, has no jaundice, and has not yet received any antidote. The pharmacy has delivered an acetylcysteine loading bag labeled 6,000 mg, matching the prescription. The acetylcysteine label directs a loading dose of 150 mg/kg. Complete the diagram by selecting the problem the client is most likely experiencing, 2 actions the nurse should take to address that problem, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617376&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question The 24-year-old client weighs 60 kg and ingested 30 immediate-release acetaminophen 500-mg tablets (15 g, 250 mg/kg) at 0100 and arrived at 0730. A timed 4-hour acetaminophen concentration drawn at 0500 at an urgent-care clinic before transfer was 185 mcg/mL. AST is 24 U/L, ALT 21 U/L, INR 1.0, and creatinine 0.8 mg/dL. The client reports nausea and mild right-upper-quadrant discomfort, has no jaundice, and has not yet received any antidote. The pharmacy has delivered an acetylcysteine loading bag labeled 6,000 mg, matching the prescription. The acetylcysteine label directs a loading dose of 150 mg/kg. Complete the diagram by selecting the problem the client is most likely experiencing, 2 actions the nurse should take to address that problem, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 Toxicity with a correctly dosed antidote order Established acute liver failure Toxicity with an underdosed antidote order Anaphylactoid reaction to acetylcysteine Actions to take Select 2 Administer activated charcoal before the infusion Premedicate with the prescribed IV diphenhydramine Recheck the acetaminophen level before starting Hold the 6,000 mg bag and clarify the dose Start the corrected loading dose without delay Parameters to monitor Select 2 Serum AST and ALT Skin flushing and urticaria INR Serum salicylate level Serum creatinine ## Explanation At 150 mg/kg, a 60-kg client needs a 9,000 mg loading dose, so the 6,000 mg order is an underdose of a time-critical antidote. The nurse holds the incorrect bag, clarifies the dose, and starts the corrected regimen promptly, because acetylcysteine is most protective within 8 to 10 hours of ingestion. AST/ALT and INR are trended to detect hepatotoxicity. ## In-depth explanation Quick answer Acetaminophen toxicity with an underdosed antidote order. Actions: hold the 6,000 mg bag and clarify the dose; start the corrected loading dose without delay. Monitor: serum AST and ALT, and INR. Why this is correct A 4-hour level of 185 mcg/mL lies well above the nomogram treatment line, so the client needs acetylcysteine. The loading dose is 150 mg/kg: 150 x 60 = 9,000 mg, so 6,000 mg is one-third too low. Liver tests are still normal, meaning injury has not yet occurred and can be prevented, but ingestion was 6.5 hours before arrival, so the corrected dose must start immediately. Transaminases and INR are the markers that show whether hepatic injury is developing. Easy analogy or mental picture Acetylcysteine is a fire crew racing a fuse: sending two-thirds of the crew (underdose) is as risky as arriving late, so fix the crew size fast and get moving. Memory hook Weigh it, times 150, check the bag, then go. NCLEX decision rule Verify weight-based doses of high-risk antidotes against the actual weight before administration, and when a dose is wrong, correct it without delaying time-critical treatment. Why the other choices are wrong A correctly dosed order is ruled out by the arithmetic. Acute liver failure would show rising AST, ALT, and INR, which are normal. An anaphylactoid reaction cannot occur before the drug is given, so diphenhydramine premedication and urticaria checks are misdirected. Activated charcoal is useful soon after ingestion, but 6.5 hours have passed and it would delay the antidote. Rechecking the level before starting is unnecessary because the timed 4-hour level is already above the treatment line. Salicylate and creatinine are not the markers of acetaminophen hepatotoxicity. References 1DailyMed — Acetylcysteine injection prescribing informationIV loading dose of 150 mg/kg; efficacy is greatest when started within 8 to 10 hours of ingestion. 2US and Canada consensus statement on acetaminophen poisoning managementManagement of acetaminophen poisoning, timing of acetylcysteine, and monitoring of hepatic injury. ## Clinical scenario Case update A 60-kg client with a timed 4-hour acetaminophen level of 185 mcg/mL and normal liver tests is about to receive an acetylcysteine loading bag of 6,000 mg instead of the 9,000 mg that 150 mg/kg requires. ## Key concepts - **Rumack-Matthew nomogram** — A graph that plots an acetaminophen level against time since ingestion to decide on treatment. - **Acetylcysteine** — The antidote for acetaminophen toxicity that replenishes glutathione and protects the liver. - **Loading dose** — The first, larger weight-based dose that rapidly achieves a therapeutic drug level. ## Related questions - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=en) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. 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