The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

Insert a nasogastric tube

Monitor airway and vital signs

Insert an indwelling urinary catheter or monitor output

Anticipate and treat hyperpyrexia with cooling measures

Answer and Explanation

The Correct Answer is B

B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.

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Correct Answer is D

Explanation

D. Furosemide is a diuretic that works by increasing urine output, which in turn reduces fluid retention and swelling. By tracking the client's weight on a daily basis, the nurse can obtain a clear and consistent measure of how much fluid is being lost as a result of the medication.
A. Monitoring respiratory status but it may not be the most direct method for evaluating the effectiveness of furosemide in reducing peripheral edema.
B. Monitoring serum protein levels may provide information about the client's nutritional status and liver function, but it is not typically used as a direct measure of response to furosemide for peripheral edema.
C. Improvement in peripheral pulses may indicate a reduction in fluid overload and resolution of edema. However, changes in peripheral pulses may be influenced by factors other than diuresis, such as vascular disease or cardiac function.

A. father and mother have different parenting styles. B. history includes antisocial behavior. C. home environment lacks organization. D. mother was stressed during pregnancy.

Correct Answer is A

Explanation

A. Separation anxiety is primarily characterized by excessive distress or fear when separated from primary caregivers, and differences in parenting styles between the child's parents may affect the child's sense of security and exacerbate separation anxiety symptoms.
B. Separation anxiety is a common childhood anxiety disorder characterized by excessive worry or fear about separation from attachment figures, such as parents or caregivers. It is not typically associated with antisocial behavior
C. Separation anxiety is primarily related to the child's emotional response to separation from attachment figures and is not necessarily caused by environmental factors such as the organization of the home.

D. Prenatal stress may contribute to the child's overall risk for anxiety disorders. However, it is not a definitive predictor of separation anxiety in childhood.

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The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

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Naxlex Comprehensive Predictor Exams

The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

Correct Answer is D

Explanation

A nurse is caring for a 6-year old child suffering from separation anxiety. Which finding would a nurse expect when assessing the child? The child's:

Correct Answer is A

Explanation

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