An adult client is brought to the emergency department by friends after consuming large amounts of alcohol over the past few days. The client is lethargic, exhibits severe ataxia, and has slurred speech. The healthcare provider has prescribed several interventions. Order the nursing actions from first to last to ensure safe and effective care.
- 1Evaluate the client's airway patency and respiratory status.
- 2Perform a bedside capillary blood glucose test.
- 3Establish peripheral intravenous (IV) access.
- 4Administer the prescribed dose of intravenous thiamine.
- 5Initiate the prescribed infusion of dextrose-containing intravenous fluids.
Answer
The correct sequence is: 1) Evaluate airway and respiratory status, 2) Perform a capillary blood glucose test, 3) Establish peripheral IV access, 4) Administer intravenous thiamine, and 5) Initiate the dextrose fluid infusion.
The priority of care for an intoxicated, lethargic client begins with the ABCs. Airway and respiratory status must be evaluated first due to the risk of respiratory depression. Next, a bedside capillary blood glucose test is essential because alcohol intoxication can cause severe hypoglycemia, which mimics worsening neurological decline. Following assessment, the nurse establishes IV access to deliver treatments. Crucially, intravenous thiamine must be administered before any dextrose-containing fluids to prevent the precipitation of Wernicke's encephalopathy, a severe neurological complication caused by thiamine depletion during glucose metabolism.
Step-by-Step Solution
Key Concept
In clients with severe alcohol intoxication or chronic use, intravenous thiamine must be administered before or simultaneously with intravenous glucose to prevent Wernicke's encephalopathy.