A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?

A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.

Potential Condition: Opioid intoxication

Actions to Take:

1. Obtain a prescription for naloxone
2. Prepare to initiate mechanical ventilation

Parameters to Monitor:

1. Pupillary reaction,
2. Respiratory rate

Rationale:

• Potential Condition: The client presents with shallow breathing, slurred speech, confusion, pupillary constriction, and bradycardia, which are classic signs of opioid intoxication. The history of back pain also suggests possible opioid use.
• Actions to Take:
  • Naloxone is an opioid antagonist that can rapidly reverse respiratory depression caused by opioid overdose.
  • Mechanical ventilation may be necessary if respiratory depression is severe and does not improve with naloxone administration.
• Parameters to Monitor:
  • Pupillary reaction is important because opioids cause pupillary constriction (miosis). Improvement in pupillary size and reaction indicates the opioid effects are wearing off.
  • Respiratory rate should be closely monitored since opioid overdose primarily affects respiratory drive, leading to hypoxia and potential respiratory failure.