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 B
Explanation
B. Oxazepam is a benzodiazepine and is often used for the management of alcohol withdrawal syndrome. It works by acting on the GABA receptors in the brain, which are the same receptors that alcohol affects, thus helping to alleviate withdrawal symptoms.
A. Fluoxetine is an antidepressant medication belonging to the class of selective serotonin reuptake inhibitors (SSRIs). It is primarily used to treat conditions like depression, anxiety disorders, obsessive- compulsive disorder (OCD), and bulimia nervosa. It is not typically used to manage alcohol withdrawal symptoms.
C. Buspirone is an anti-anxiety medication used to treat generalized anxiety disorder (GAD). It works differently from benzodiazepines and is not typically used to manage alcohol withdrawal symptoms.
D. Amitriptyline is a tricyclic antidepressant used to treat depression, neuropathic pain, and sometimes migraines. Like fluoxetine, it is not typically used to manage alcohol withdrawal symptoms.
Correct Answer is A
Explanation
A. Turkey contains tryptophan, which can have a calming effect and aid in sleep, while cheese provides calcium, and milk is a good source of protein and hydration.
B. Fried foods can be heavy and may exacerbate agitation or restlessness. Additionally, mashed potatoes are high in simple carbohydrates, which may cause rapid spikes and crashes in energy levels.
C. Chips are typically high in unhealthy fats and low in essential nutrients, and cola provides little to no nutritional value while containing high amounts of sugar and caffeine, which may exacerbate symptoms of mania.
D. Caffeine content in tea may not be ideal for someone experiencing mania, as it can further stimulate agitation or hyperactivity.
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