A nurse is assisting in the care of a client in an outpatient substance use disorder clinic who has been taking naltrexone for the past 30 days. Which of the following client statements indicates an expected response to the treatment?

Rationale:

A. Changing a sterile dressing on a client's open wound: Sterile procedures require nursing judgment and knowledge of aseptic technique. This task falls within the scope of practice for licensed nurses, not assistive personnel.

B. Performing postmortem care for a client: Postmortem care, such as cleaning the body and preparing it for transport, is a non-sterile, routine task that can be safely delegated to assistive personnel in accordance with facility policy and under nurse supervision.

C. Interpreting a client's laboratory values: Interpretation of lab results requires clinical judgment and is the responsibility of licensed personnel. Assistive personnel are not trained or authorized to interpret clinical data.

D. Inserting a client's NG tube: Inserting a nasogastric tube is an invasive procedure that requires assessment and verification of placement. This task is beyond the scope of assistive personnel and should be performed by a nurse.

Rationale:

A. Ask the client to describe the incident: The first step is to gather detailed and accurate information about what happened. This not only allows the nurse to assess the severity and risk of harm but also builds trust with the client. Understanding the specifics of the situation is essential before planning further interventions.

B. Assist the client with developing a safety plan: While crucial for long-term well-being, safety planning should come after assessing the current situation. The nurse must first understand the context of the incident to tailor the plan effectively and ensure it aligns with the client’s readiness and safety.

C. Provide the client with information about local shelters: Offering shelter information is supportive and may be part of discharge or follow-up teaching. However, this should follow the initial assessment, as the client may not yet be ready to consider leaving or may have specific needs not met by general resources.

D. Refer the client to a support group: Support groups are helpful for emotional healing and connection but are not an immediate priority. Without understanding the client’s current circumstances, risk level, and readiness to engage, such a referral may not be appropriate at this stage.