The nurse is caring for a client who just received naloxone. Which nursing intervention is the highest priority?

Choice A Reason: Insert a nasogastric tubeThis choice is incorrect. Inserting a nasogastric tube is not the highest priority intervention for a client who has just received naloxone. While it may be necessary in some cases for other reasons, the immediate concern after naloxone administration is to ensure the client’s airway is open and they are breathing adequately. Naloxone reverses opioid effects, which can cause respiratory depression, so monitoring the airway and vital signs is crucial.Choice B Reason: Monitor airway and vital signsThis choice is correct. The highest priority after administering naloxone is to monitor the client’s airway and vital signs. Naloxone can rapidly reverse opioid-induced respiratory depression, but its effects may wear off before the opioids are completely metabolized, leading to a risk of re-sedation and respiratory depression. Continuous monitoring ensures that any changes in the client’s condition are detected and managed promptly.Choice C Reason: Insert an indwelling urinary catheter or monitor outputThis choice is incorrect. While monitoring urine output can be important in assessing overall kidney function and fluid balance, it is not the highest priority immediately after naloxone administration. The primary concern is the client’s respiratory status and ensuring they maintain an open airway and adequate ventilation.Choice D Reason: Anticipate and treat hyperpyrexia with cooling measuresThis choice is incorrect. Hyperpyrexia (extremely high fever) is not a common immediate concern following naloxone administration. The primary focus should be on the client’s respiratory status and vital signs. Treating hyperpyrexia would be important if it were present, but it is not typically associated with naloxone administration.