Prevention and education
Prevention and education ( 10 Questions)
A nurse is caring for a client who has been admitted to the hospital for an overdose of a controlled substance. The nurse suspects that the client has been abusing multiple drugs based on the client's signs and symptoms. Which of the following actions should the nurse take first?
This is an important action, but not the first one. The nurse should notify the health care provider and request an order for a urine drug screen after assessing the client and stabilizing their condition. A urine drug screen can help to identify the type and amount of drugs that the client has ingested and guide the treatment plan.
This is an important action, but not the first one. The nurse should administer naloxone as prescribed to reverse the effects of opioids after assessing the client and confirming that they have signs of opioid toxicity, such as pinpoint pupils, decreased respiratory rate, and decreased level of consciousness. Naloxone is an opioid antagonist that can rapidly restore normal respiration and alertness in opioid overdose cases. However, naloxone has no effect on other types of drugs and may precipitate withdrawal symptoms in opioid-dependent clients.
Rationale: The first action that the nurse should take when using the nursing process is to assess the client. Assessing the client's vital signs and level of consciousness is essential to determine the severity of the overdose and the need for immediate interventions. The nurse should also monitor the client for signs of respiratory depression, cardiac arrhythmias, seizures, or other complications.
This is an important action, but not the first one. The nurse should educate the client about the risks and consequences of drug abuse after assessing the client and ensuring their safety and stability. The nurse should also provide emotional support and refer the client to appropriate resources for substance abuse treatment and recovery.
Correct answer: c) Assess the client's vital signs and level of consciousness.
Rationale: The first action that the nurse should take when using the nursing process is to assess the client. Assessing the client's vital signs and level of consciousness is essential to determine the severity of the overdose and the need for immediate interventions. The nurse should also monitor the client for signs of respiratory depression, cardiac arrhythmias, seizures, or other complications.
Incorrect choices:
a) Notify the health care provider and request an order for a urine drug screen.: This is an important action, but not the first one. The nurse should notify the health care provider and request an order for a urine drug screen after assessing the client and stabilizing their condition. A urine drug screen can help to identify the type and amount of drugs that the client has ingested and guide the treatment plan.
b) Administer naloxone as prescribed to reverse the effects of opioids.: This is an important action, but not the first one. The nurse should administer naloxone as prescribed to reverse the effects of opioids after assessing the client and confirming that they have signs of opioid toxicity, such as pinpoint pupils, decreased respiratory rate, and decreased level of consciousness. Naloxone is an opioid antagonist that can rapidly restore normal respiration and alertness in opioid overdose cases. However, naloxone has no effect on other types of drugs and may precipitate withdrawal symptoms in opioid-dependent clients.
d) Educate the client about the risks and consequences of drug abuse.: This is an important action, but not the first one. The nurse should educate the client about the risks and consequences of drug abuse after assessing the client and ensuring their safety and stability. The nurse should also provide emotional support and refer the client to appropriate resources for substance abuse treatment and recovery.