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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Nylon socks should be avoided as they do not allow moisture to escape, which can promote fungal infections.

B. Toenails should be trimmed straight across rather than rounded to prevent ingrown toenails, which can lead to infections.

C. This is the correct answer. Clients with peripheral vascular disease (PVD) should use lamb’s wool between toes that rub together to prevent pressure ulcers and skin breakdown.

D. Compression stockings can be harmful in PVD if not prescribed by a provider because they may impair circulation further.

A. Call the nurse who made the error to discuss the medication error. B. File an incident report within 24 hr. C. Notify the facility's pharmacist within 1 hr of the incident. D. Place an incident report in the client's medical record.

Correct Answer is B

Explanation

Rationale:

A. Call the nurse who made the error to discuss the medication error – This is not the appropriate action. The focus should be on client safety and proper reporting, not on discussing the error with the previous nurse.

B. File an incident report within 24 hr – This is the correct action. Incident reports should be completed promptly to document the error and ensure proper follow-up.

C. Notify the facility's pharmacist within 1 hr of the incident – While the pharmacist may be informed if a medication reversal or adjustment is needed, this is not the primary action to take.

D. Place an incident report in the client’s medical record – Incident reports are internal documents and should not be placed in the medical record to avoid legal concerns.

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