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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Histrionic personality disorder (HPD) is characterized by a pattern of excessive emotionality and attention-seeking behavior. Individuals with HPD often display dramatic, flamboyant, or exaggerated emotions and may use seductive or provocative behavior to capture the attention of others.
A. Histrionic personality disorder (HPD) is characterized by attention-seeking behavior, emotional instability, and a strong desire for excitement and novelty. They are less likely to be preoccupied with minute details or exhibit perfectionistic traits, which are more commonly associated with obsessive- compulsive personality disorder (OCPD).
B. Grandiosity, self-importance, and a sense of entitlement are characteristic features of narcissistic personality disorder (NPD), not histrionic personality disorder (HPD).
C. Difficulty being alone, indecisiveness, and submissiveness are more commonly associated with dependent personality disorder (DPD), not histrionic personality disorder (HPD).
Correct Answer is C
Explanation
C. This statement raises significant concern for possible emotional or psychological abuse. Comparing the child unfavorably to siblings and implying that the child is not as "good" as others could indicate a pattern of emotional maltreatment.
A. This statement does not raise suspicion of child abuse. It merely describes the child's intelligence and does not provide any indication of potential abuse.
B. it is possible for children to sustain injuries due to clumsiness or accidents but this statement alone does not necessarily raise suspicion of child abuse.
D. This statement, on its own, does not necessarily indicate child abuse.
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