A client with suspected acute cocaine toxicity is brought to the emergency department. The client is profoundly restless, diaphoretic, and reports severe, crushing chest pain. In what order should the practical nurse (PN) prioritize the following actions? Arrange the actions from first to last.
- 1Verify the client's airway patency and assess respiratory effort.
- 2Attach the client to continuous cardiac monitoring equipment.
- 3Measure the client's complete vital signs, including body temperature.
- 4Decrease environmental stimuli by dimming the lights and minimizing noise.
- 5Assist the registered nurse (RN) with preparing a prescribed intravenous benzodiazepine.
Answer
The correct sequence is to first verify airway patency, then attach cardiac monitoring, obtain complete vital signs, decrease environmental stimuli, and finally assist with administering the prescribed benzodiazepine.
In acute substance toxicity emergencies, care is prioritized using Maslow's hierarchy of needs and the ABCs (Airway, Breathing, Circulation). The nurse must first ensure an open airway and adequate breathing. Next, because cocaine toxicity severely compromises the cardiovascular system, continuous cardiac monitoring is established to detect life-threatening dysrhythmias. Following this, completing the primary data collection with full vital signs (including temperature to check for hyperthermia) is essential. Once physiological stability is assessed, the nurse implements environmental safety measures by decreasing stimuli to reduce agitation. Finally, the nurse assists the RN with pharmacological interventions, such as benzodiazepines, which are the treatment of choice for cocaine-induced agitation and cardiovascular toxicity.
Step-by-Step Solution
Key Concept
Prioritization of Care in Substance Toxicity (ABCs and Nursing Process)