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
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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Related Questions
Correct Answer is C
Explanation
C. Administering naloxone is often the priority action for a client exhibiting symptoms of opiate intoxication, especially if they are experiencing significant respiratory depression or unconsciousness. Naloxone is a medication used to rapidly reverse the effects of opioids, including respiratory depression and sedation.
A. Opening the crash cart is not the priority action for a client exhibiting symptoms of opiate intoxication unless the client's condition deteriorates rapidly, leading to a life-threatening emergency such as respiratory depression or cardiac arrest.
B. This intervention is important for clients experiencing respiratory depression, hypoxemia, or altered mental status due to opiate overdose. However, it may not be the highest priority action if the client's respiratory status is stable
D. Contacting the client's parents or guardians is important for obtaining medical history, consent for treatment (if applicable), and support. However, it may not be the highest priority action in the immediate management of opiate intoxication.
Correct Answer is B
Explanation
B. Olanzapine is an antipsychotic medication commonly used to treat acute manic episodes in bipolar disorder. It can help to stabilize mood, reduce agitation, and calm hyperactivity while waiting for lithium to reach therapeutic levels and take effect.
A. Olanzapine is an antipsychotic medication that can have sedative effects and may help with sleep but this statement does not directly address the reason for its use in this specific situation.
C. Like other medications used to treat bipolar disorder, does not cure the condition. Instead, it helps to manage and stabilize symptoms, including manic episodes, by regulating neurotransmitter activity in the brain.
D. Olanzapine is an antipsychotic medication that has a lower risk of causing extrapyramidal side effects compared to typical antipsychotics but this statement does not accurately explain its use in this scenario.
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