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 C

Explanation

A. Healthy weight – A BMI between 18.5 and 24.9 is classified as healthy. Since the client's BMI is 17.2, they do not fall within this range.

B. Overweight – Overweight is defined as a BMI between 25.0 and 29.9. The client's BMI of 17.2 is far below this range.

C. Underweight – A BMI below 18.5 is classified as underweight. Since the client's BMI is 17.2, they fall into this category. Clients with Crohn’s disease often experience malabsorption and weight loss, leading to a low BMI.

D. Obesity class 1 – Obesity is categorized as a BMI of 30.0 or higher. The client’s BMI is far below this classification.

A. Empty the collection chamber every 8 hr. B. Check the patency of the tubing every 2 hr. C. Keep the drainage system above the level of the client's chest. D. Ensure 2 cm (0.8 in) of water is in the water seal chamber.

Correct Answer is D

Explanation

A. Empty the collection chamber every 8 hr – Incorrect. The collection chamber is not emptied; instead, it is replaced when full to prevent air re-entry.

B. Check the patency of the tubing every 2 hr – While monitoring the tubing is essential, checking patency is not the most specific nursing priority.

C. Keep the drainage system above the level of the client's chest – Incorrect. The system should remain below chest level to prevent backflow of drainage.

D. Ensure 2 cm (0.8 in) of water is in the water seal chamber – Correct. The water seal chamber maintains negative pressure and prevents air from entering the pleural space, making this a crucial step in chest tube management.

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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

A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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