nurse is teaching a client who has a new prescription for captopril. Which of the following information should the nurse include in the teaching?

A. “Heart rate”: While it’s important to monitor the heart rate of a client who has received naloxone, it’s not the first assessment that should be made. Opioid toxicity can lead to life-threatening respiratory depression, so the priority is to assess the client’s respiratory status.

B. “Pain level”: Pain level is an important consideration when administering any medication, but it’s not the first assessment to be made following naloxone administration. The priority is to assess the client’s respiratory status, as opioid toxicity can cause life-threatening respiratory depression.

C. “Blood pressure”: Monitoring blood pressure is important in any client receiving medication, but it’s not the first assessment to be made following naloxone administration. The priority is to assess the client’s respiratory status, as opioid toxicity can cause life-threatening respiratory depression.

D. “Breath sounds”: This is the correct answer. The primary risk with opioid toxicity is respiratory depression, which can be life-threatening. Naloxone is administered to reverse this effect. Therefore, the nurse should first assess breath sounds to determine if the client’s respiratory status is improving.

A. “Give diphenhydramine IM”: While diphenhydramine, an antihistamine, can be used in the treatment of allergic reactions, it is not the first-line treatment for anaphylaxis. Anaphylaxis is a severe, potentially life-threatening allergic reaction that requires immediate treatment with epinephrine.

B. “Administer epinephrine IM”: Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to reverse the life-threatening symptoms of anaphylaxis, including airway swelling and severe low blood pressure. Therefore, after stopping the medication infusion and assessing the client’s respiratory status, the nurse should administer epinephrine IM.

C. “Replace the infusion with 0.9% sodium chloride”: While replacing the infusion with 0.9% sodium chloride (normal saline) can help maintain venous access and hydration, it is not the immediate priority in the treatment of anaphylaxis. The first priority is to administer epinephrine.

D. “Elevate the client’s legs and feet”: Elevating the client’s legs and feet can help improve blood flow and may be beneficial in the treatment of anaphylaxis. However, it is not the immediate priority. The first priority is to administer epinephrine. After administering epinephrine and ensuring the client’s airway is open, the nurse can then take measures to make the client more comfortable, such as elevating the legs and feet.