A nurse is collecting data on a client who has a surgical wound healing by secondary intention.
Which of the following findings should the nurse report to the charge nurse?

Choice A rationale

Naloxone, an opioid antagonist, is not indicated for treating urinary retention, which can be a side effect of opioid agonists like fentanyl due to increased tone of the detrusor muscle and sphincter. While discontinuing the opioid may resolve retention, naloxone's primary action is to reverse acute opioid-induced central nervous system and respiratory depression by competitive antagonism at opioid receptors, not to manage genitourinary dysfunction.

Choice B rationale

Nausea and vomiting are common side effects of opioid analgesics, mediated by stimulation of the chemoreceptor trigger zone in the medulla. While reversing the opioid effects with naloxone will subsequently reduce this symptom, naloxone is generally reserved for life-threatening opioid toxicity. Antiemetics like ondansetron or prochlorperazine are the standard pharmacological treatment for opioid-induced nausea.

Choice C rationale

Naloxone is a potent, rapid-acting opioid antagonist that competitively binds to and blocks opioid receptors, particularly μ (mu) receptors, in the central nervous system. This action effectively reverses the agonistic effects of opioids, such as respiratory depression, sedation, and analgesia, making it the essential treatment for acute opioid overdose.

Choice D rationale

Opioids can cause dryness of respiratory secretions due to their anticholinergic-like effects, not increased secretion. Naloxone's mechanism of action does not involve suppressing secretions; it specifically reverses the central nervous system depression caused by opioid agonists by competitively binding to opioid receptors. Standard treatments for excessive respiratory secretions involve suctioning or anticholinergic agents like atropine.

Choice A rationale

Notifying the client's provider is a necessary step after the immediate needs and physical assessment of the client are addressed and completed. The immediate priority following a fall is to ensure the client is safe, prevent further injury, and determine the extent of harm before reporting the incident to the healthcare provider for further medical orders.

Choice B rationale

Obtaining the client's vital signs is part of the assessment phase following a fall to establish a baseline and detect signs of injury (e.g., hypotension, shock). However, the initial priority is to safely return the client to the bed, which addresses the immediate risk of the client remaining on the cold, hard floor and attempting to move unsafely.

Choice C rationale

Assisting the client back into bed is the most immediate priority following a fall to ensure client safety and prevent complications such as hypothermia, pressure injury, or further injury from movement. This action addresses the immediate physical need before assessment, notification, or family communication can be effectively and safely performed.

Choice D rationale

Informing the client's family member is an important step in client and family communication regarding an adverse event. However, this is a subsequent step that must occur after the client's physical safety is secured, immediate care needs are met, and a thorough assessment of the fall and any resultant injuries has been performed.