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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 B

Explanation

Using active listening techniques and providing a supportive and non-judgmental environment can promote the client's ability to express their feelings. Many clients facing end-stage illnesses, such as alcoholic cirrhosis, may experience a range of emotions and find it difficult to talk about their illness or impending loss of life. By being present, attentive, and using silence when appropriate, the nurse allows the client the space and time they need to process their thoughts and emotions and feel comfortable expressing their feelings when they are ready.

Incorrect:

Option A may come across as confrontational and judgmental, which can hinder the client's willingness to share their feelings.

Option C may be appropriate if the client requests spiritual or religious support, but it should not be assumed as the primary intervention for promoting emotional expression.

Option D can be seen as dismissive and insensitive to the client's emotional needs, and it may not be helpful in encouraging the client to open up about their feelings.

A. Call security and ask them to detain the client from leaving. B. Contact the client's family to request they convince the client to stay. C. Allow the client to leave, with a referral to community resources for follow-up care. D. Contact the psychiatrist for initiation of commitment proceedings.

Correct Answer is D

Explanation

In this situation, the client's safety is of utmost importance. Expressing a desire to leave the facility and harm oneself with a gun raises serious concerns about the client's safety and the risk of harm to themselves. Initiating commitment proceedings, also known as involuntary hospitalization or psychiatric hold, allows the facility to legally detain the client temporarily for their protection and evaluation by mental health professionals. This allows for a thorough assessment of the client's mental health status and the formulation of a comprehensive treatment plan to ensure their safety.

Options A, B, and C are not appropriate in this situation:

A. Calling security to detain the client may escalate the situation and could potentially lead to increased risk of harm.

B. Contacting the client's family may not be enough to ensure the client's safety, and it is essential to involve mental health professionals in evaluating the client's risk.

C. Allowing the client to leave without addressing their expressed suicidal ideation is not safe, as the client may be at high risk for self-harm or suicide. Simply referring them to community resources without further evaluation and intervention is not sufficient to address the immediate safety concern.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

Correct Answer is D

Explanation

A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on the appropriate use of seclusion?

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 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 nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

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?

A nurse is working with a client who has frequent angry outbursts which is disrupting life at home. Which statement by the nurse is most helpful when working with this client?