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 A
Explanation
A. Lithium carbonate is a medication commonly used to treat bipolar disorder. Symptoms of lithium toxicity can include nausea, vomiting, diarrhea, muscle weakness, tremors, and flu-like symptoms. If a client is experiencing these symptoms after taking lithium carbonate, it could indicate lithium toxicity
B. Lithium is a mood stabilizer, and tolerance, in the sense of needing increasing doses to achieve the same effect, is not commonly observed.
C. Suddenly stopping lithium carbonate can lead to withdrawal symptoms, but the symptoms described— nausea, diarrhea, muscle weakness, and tremors—are more indicative of toxicity rather than withdrawal.
D. Tyramine is a compound found in certain foods and beverages, and interactions between tyramine-rich foods and certain medications, such as monoamine oxidase inhibitors (MAOIs), can lead to hypertensive crises. However, lithium carbonate is not known to have interactions with tyramine-rich foods.
Correct Answer is C
Explanation
C. This attitude suggests a sense of self-blame or low self-worth commonly seen in individuals with depression. They may feel undeserving of happiness or believe that their suffering is justified. This attitude can hinder the individual's willingness to seek help or engage in treatment, as they may believe that they do not deserve support or that their situation is hopeless.
A. This attitude may reflect optimism or hopefulness which is not a common finding in individuals with depression. Hopelessness is more common in depression.
B. This attitude reflects a sense of determination and agency in overcoming the illness. This is not a typical finding in depression.
D. Some individuals with depression may attempt to cope by minimizing or ignoring their symptoms, hoping that they will resolve on their own. However, untreated depression typically does not improve without intervention and may worsen over time.
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