A nurse is caring for a group of patients on an adult medical-surgical unit.
Which patient should the nurse identify as having the highest risk for aspiration?

Choice A rationale:

Pallor, or paleness, is not a typical sign of phlebitis. It can be associated with other conditions such as anemia, decreased blood flow, or shock. In the context of IV therapy, pallor at the insertion site might suggest a problem with blood flow, such as infiltration or a clot, but it's not a direct indication of inflammation.

Choice B rationale:

Coolness at the IV site is also not a characteristic sign of phlebitis. It could potentially suggest infiltration of the IV fluids into the surrounding tissues, but it's not a primary indicator of inflammation. Phlebitis typically involves warmth and redness due to the inflammatory response.

Choice C rationale:

Erythema, or redness, is the hallmark sign of phlebitis. It's caused by the dilation of blood vessels in the area as part of the inflammatory response. The redness is often accompanied by warmth, swelling, and tenderness along the vein.

Mechanism of erythema in phlebitis:

When the inner lining of the vein (endothelium) is irritated or damaged by the IV catheter, it releases inflammatory mediators. These mediators cause the blood vessels to dilate, leading to increased blood flow and redness in the area.

The redness is often more pronounced along the path of the vein, rather than just at the insertion site.

Choice D rationale:

Drainage from the IV site can be a sign of infection, but it's not a primary feature of phlebitis. If drainage is present, it's important to assess for other signs of infection, such as pus, fever, or increased pain.

Choice A rationale:

Naloxone does not have any direct effect on respiratory secretions. It works by binding to opioid receptors in the brain and reversing the effects of opioids, such as respiratory depression.

While opioids can cause a decrease in respiratory secretions, this is not the primary reason for administering naloxone.

It is important to note that naloxone can actually worsen respiratory secretions in some patients, particularly those with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.

Choice B rationale:

Naloxone is a medication that is specifically designed to block the effects of opioids on the central nervous system (CNS).

It is a competitive antagonist, which means that it binds to opioid receptors in the brain and prevents opioids from binding to those receptors.

This can reverse the effects of opioids, such as respiratory depression, sedation, and hypotension.

Naloxone is often used to treat opioid overdose, but it can also be used to prevent opioid-induced respiratory depression in patients who are receiving opioids for pain relief.

Choice C rationale:

Naloxone is not effective in treating nausea.

In fact, it can actually worsen nausea in some patients.

This is because naloxone can block the effects of opioids in the brain, and opioids can sometimes have a nausea-relieving effect.

Choice D rationale:

Naloxone is not effective in treating urinary retention.

Urinary retention is a common side effect of opioids, but it is not caused by the effects of opioids on the CNS. Urinary retention is typically caused by the effects of opioids on the bladder muscles.