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A nurse in the emergency department is preparing to administer naloxone 0.4 mg IV bolus to a client who has opioid-induced respiratory depression. Available is naloxone injection 0.2 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer and Explanation

The Correct Answer is ["2"]

To calculate the amount of naloxone to administer, you can use the following formula:

Amount to administer (mL) = Total dose required (mg) / Concentration of drug (mg/mL)

Given:

Total dose required = 0.4 mg

Concentration of drug = 0.2 mg/mL

Let's calculate the amount to administer:

Amount to administer (mL) = 0.4 mg / 0.2 mg/mL

Now, perform the calculation:

Amount to administer (mL) = 2 mL

So, the nurse should administer 2 mL of naloxone intravenously as a bolus dose to the client.

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Correct Answer is ["0.6"]

Explanation

Step 1: Determine the dosage available per mL.

Available dosage is 8 mg in 0.4 mL.
Calculation: 8 mg ÷ 0.4 mL = 20 mg/mL.
Result: 20 mg/mL.

Step 2: Calculate the volume needed for 12 mg.

Required dosage is 12 mg.
Calculation: 12 mg ÷ 20 mg/mL = 0.6 mL.
Result: 0.6 mL.

So, the nurse should administer 0.6 mL of methylnaltrexone.

A. Prior to performing any intervention that requires touch, the nurse will ask permission. B. Have the client perform all care independently and without assistance. C. Have two nurses present at all times in which to perform all care and procedures. D. The nurse will perform a continuous assessment of the client's anxiety level. E. Have security present outside of the client's room to prevent anyone from coming in.

Correct Answer is ["A","D","E"]

Explanation

The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:

A. Prior to performing any intervention that requires touch, the nurse will ask permission.

This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.

D. The nurse will perform a continuous assessment of the client's anxiety level.

Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.

E. Have security present outside of the client's room to prevent anyone from coming in.

Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.

It is not appropriate to:

B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.

C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["0.6"]

Explanation

The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A client who has been physically aggressive arrives at the emergency department for a psychiatric assessment. Which approach would be best for the nurse to use?

A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)

The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior?

A client with end-stage alcoholic cirrhosis of the liver is hesitant to talk about the illness and the impending loss of life from their alcohol use disorder. Which action by the nurse can promote the client's ability to express their feelings?

A client has just had an elective abortion to end an unintended pregnancy. Afterward, the client cries because although they wanted to have children in future years, this pregnancy was not well timed. Which type of grief is this client most likely to experience?

A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

The health care provider prescribes haloperidol 10 mg for a client with severe psychosis but the client refuses the medication. Which nursing action is appropriate?

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?