Question

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

a. Administer activated charcoal.
b. Administer naloxone.
c. Initiate gastric lavage.
d. Monitor vital signs.

Answer 1

To provide care for a client with alcohol toxicity who is unresponsive, the nurse should monitor vital signs to detect and respond to any life-threatening changes promptly.

Step-by-step explanation:

The nurse caring for a client with alcohol toxicity who is unresponsive should prioritize interventions that support vital life functions. The most appropriate intervention, in this case, is to monitor vital signs. This involves assessing the patient's heart rate, blood pressure, respiratory rate, and temperature to detect any life-threatening changes that would require immediate action. While options such as administering activated charcoal or initiating gastric lavage could be considered in some cases of poisoning or overdose, these are not standard interventions for alcohol toxicity, especially if the patient is already unresponsive. Naloxone is an opioid antagonist and not effective for alcohol toxicity. Keeping a close watch over the vital signs allows the nurse to react promptly to any deterioration in the patient's condition, ensuring safety and the provision of timely medical interventions.

Answer 2

Monitoring vital signs is crucial in managing a client with alcohol toxicity who is unresponsive. Vital signs, including heart rate, respiratory rate, blood pressure, and oxygen saturation, provide essential information about the client's physiological status. This continuous assessment helps the nurse identify any signs of deterioration or improvement, guiding further interventions as needed. So, The correct option is d. Monitor vital signs.

Step-by-step explanation:

In managing a client with alcohol toxicity who is unresponsive, the most appropriate intervention is to monitor vital signs, making option d the correct choice. Vital signs encompass key physiological parameters, including heart rate, respiratory rate, blood pressure, and oxygen saturation, which collectively offer a comprehensive snapshot of the patient's current health status.

In cases of alcohol toxicity, these indicators are particularly crucial due to the potential for respiratory depression, cardiovascular instability, and compromised oxygenation. Continuous monitoring of vital signs enables the nurse to detect any fluctuations or abnormalities promptly. For instance, a decline in oxygen saturation or respiratory rate may indicate respiratory distress, necessitating swift intervention.

Conversely, improvements in vital signs could signify a positive response to prior interventions or the natural course of detoxification. This real-time assessment provides valuable information that guides subsequent nursing actions, ensuring that the care provided is tailored to the evolving needs of the patient.