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 B

Explanation

B. Multiple visits of the same child with different injuries could be a significant red flag for possible child abuse. Patterns of repeated injuries or injuries inconsistent with the child's developmental stage or reported activities may indicate a pattern of maltreatment.
A. While accidental injuries can occur, a dislocated shoulder in a 1-year-old child from arm swinging seems unlikely and may warrant further investigation.
C. Breaking a bone, such as an arm, can occur accidentally during childhood play or activities and the behavior of the child clinging to the mother is expected in moments of pain.
D. Middle ear infections are common in childhood and typically do not raise suspicion of abuse on their own.

A. sodium of 133 mg/dl. B. glucose of 110 mg/dl. C. potassium of 3.0 mEq/L. D. calcium of 9.0 mg/dl.

Correct Answer is C

Explanation

C. Digoxin toxicity is a serious condition that can occur when there is too much digoxin in the body. It can lead to life-threatening cardiac dysrhythmias. One of the risk factors for digoxin toxicity is low blood levels of potassium, or hypokalemia.
A. Electrolyte imbalances, including hyponatremia (low sodium levels), can contribute to digoxin toxicity. However, a sodium level of 133 mg/dl alone does not directly indicate digoxin toxicity.
B. Blood glucose levels within the normal range (80-120 mg/dl) would not directly indicate digoxin toxicity.
D. Calcium levels within the normal range (8.5-10.5 mg/dl) do not directly indicate digoxin toxicity.

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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

Several children are seen in the ER for treatment of illnesses and injuries daily. The situation that would cause the nurse to have a high suspicion of child abuse would be:

Correct Answer is B

Explanation

The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

Correct Answer is C

Explanation

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