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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. The combination of paroxetine and St. John's Wort can lead to a potentially life-threatening condition known as serotonin syndrome. It is important for healthcare providers to be aware of potential drug interactions and to monitor patients closely when changes to their medication regimen occur.
A. Using a heating pad may provide temporary relief for muscle stiffness but does not address the underlying cause of the symptoms.
C. Given the symptoms described, involving an orthopedic doctor is not appropriate as the symptoms are not related to musculoskeletal issues.
D. A clear liquid diet and bed rest do not address the underlying issue in the client hence not an appropriate action.
Correct Answer is A
Explanation
A. Conduct Disorder is characterized by a repetitive and persistent pattern of behavior that violates the rights of others or major age-appropriate societal norms or rules. It often includes aggressive behavior towards people or animals, destruction of property, deceitfulness or theft, and serious violations of rules.
B. Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by difficulties in social interaction and communication, as well as restricted and repetitive patterns of behavior, interests, or activities.
C. Oppositional behavior is present in ODD but the severity and nature of the behaviors described in the scenario (prostitution, running away, and abuse towards parents) are more consistent with Conduct Disorder rather than ODD.
D. Childhood depression, also known as pediatric depressive disorder, involves persistent feelings of sadness, hopelessness, or irritability that interfere with daily functioning.
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