A nurse is preparing to administer naloxone IV bolus to a client who has opioid use disorder and has developed acute opioid toxicity. Which of the following actions should the nurse take?

Check the client's vital signs every 15 min.

Give the naloxone slowly for 15 seconds.

Expect the onset of naloxone to occur in 15 min.

Anticipate the effects of naloxone to last for 24 hr.

Answer and Explanation

The Correct Answer is A

A. Vital signs should be monitored every 15 minutes because naloxone has a short duration and the client may experience opioid re-sedation as the antagonist wears off.

B. Naloxone should be administered over 2 minutes, not 15 seconds, to reduce abrupt opioid withdrawal symptoms.

C. Naloxone has a rapid onset (1-2 minutes IV, 2-5 minutes IM).

D. The effects of naloxone last only 30-90 minutes, requiring repeated doses if opioids are still in the system.

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Correct Answer is D

Explanation

A. Asking about body changes is important for understanding the client’s self-perception, but it does not address immediate safety concerns.

B. Inquiring about the duration of feelings of uselessness is helpful for assessing depressive symptoms, but it is not the priority over assessing for suicidal intent.

C. Exploring triggers for these feelings is useful for emotional support and planning interventions but is secondary to assessing for immediate risk of self-harm.

D. This question assesses for suicidal ideation, which is the nurse’s priority because older adults experiencing feelings of uselessness or hopelessness are at higher risk for depression and suicide. Early identification of suicidal thoughts ensures prompt intervention and support.

A. Dry mouth B. Constipation C. Insomnia D. Excessive sweating

Correct Answer is D

Explanation

A. Dry mouth is a common side effect but not a sign of serotonin syndrome.

B. Constipation is another possible side effect but is not an emergency.

C. Insomnia can occur but does not indicate serotonin syndrome.

D. This is the correct answer. Excessive sweating (along with agitation, confusion, fever, and muscle rigidity) is a sign of serotonin syndrome, a potentially life-threatening condition.

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A nurse is preparing to administer naloxone IV bolus to a client who has opioid use disorder and has developed acute opioid toxicity. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is preparing to administer naloxone IV bolus to a client who has opioid use disorder and has developed acute opioid toxicity. Which of the following actions should the nurse take?