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 D

Explanation

D. Engaging in play activities can indicate that the child is focusing their energy positively and is able to engage with their environment in a constructive way. Play can also serve as a therapeutic tool that helps children with ADHD improve their attention, reduce hyperactive behavior, and learn social skills.
A. Manipulative behaviors may not be directly related to the core symptoms of ADHD, but they can be present in some children with ADHD as a way of coping with difficulties in attention and impulse control.
B. Redirection of violent behaviors involves guiding the child towards more appropriate and non-violent ways of expressing their emotions and frustrations. Monitoring for successful redirection of violent behaviors would indicate progress in improving impulse control and emotional regulation.
C. Withdrawal when frustrated is not a desired outcome for a child with ADHD. Instead, the goal is typically to help the child develop coping strategies to manage frustration constructively and remain engaged in activities.

A. must perform other psychomotor tests to determine intoxication. B. is legally intoxicated. C. would be considered intoxicated depending on state law requirements. D. has a BAL within legal limits.

Correct Answer is B

Explanation

B. In the United States, the legal limit for blood alcohol concentration (BAC) is 0.08%. A BAC of 0.11 g/dL exceeds this limit, indicating that the client is indeed legally intoxicated.
A. Psychomotor tests, such as field sobriety tests, may be performed to assess the client's level of impairment and determine if they are intoxicated when the BAL is below threshold for intoxication.
C. State laws do not vary in this regard for the legal limit of BAC for driving; however, penalties and specific charges can vary from state to state.
D. A blood alcohol level (BAL) of 0.11 g/dL is above the legal limit for driving in many jurisdictions, where the legal limit is typically set at 0.08 g/dL.

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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 7-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. The nurse should monitor for which desired outcome?

Correct Answer is D

Explanation

A client is seen in the Emergency Department (ED) following a motor vehicle accident. The client's blood alcohol level (BAL) is 0.11 g/dL. The nurse assesses that this client:

Correct Answer is B

Explanation

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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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