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 ["C","D","E"]

Explanation

C. Identifying community resources is essential as it provides the client with accessible support during crises.
D. Educating the family about creating a safe and structured environment is also important because it involves the client's support system in their care, which can help prevent future crises.
E. Assisting the client in developing more effective coping mechanisms is vital for long-term management and recovery, as it empowers the client to handle stressors more healthily.
A. Isolating the client from all stressful situations is not practical or beneficial as it does not teach coping mechanisms or resilience.
B. Having a one-to-one sitter might be necessary in some inpatient settings but is not feasible or indicated for outpatient care.

A. calling staff to place the child in the locked seclusion room. B. placing the child in physical restraints. C. providing a prn anxiolytic medication. D. suggesting that the child go into the gym and shoot some baskets.

Correct Answer is D

Explanation

D. It offers the child a constructive way to release pent-up energy and frustration in a safe and non- confrontational manner. Physical activity can be a helpful tool in managing anger and disruptive behavior, as it allows the child to channel their emotions into a productive activity.
A. This option is not appropriate because it involves isolating the child in a locked room, which could further escalate the situation and may traumatize the child. Seclusion should only be used as a last resort in situations where the child or others are at risk of harm.
B. Physical restraints should only be used as a last resort in situations where the child poses an immediate danger to themselves or others. Using physical restraints can escalate the situation and may cause physical and psychological harm to the child.
C. Medication may be prescribed to manage symptoms of oppositional defiant disorder. However, using a PRN (as needed) anxiolytic medication to manage acute agitation should only be done under the guidance of a healthcare provider.

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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

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is D

Explanation

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