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. Switch to a lactose-free formula – A lactose-free formula is necessary for clients with lactose intolerance but does not address the issue of hyperosmolar dehydration, which results from insufficient free water intake rather than intolerance to lactose.

B. Reposition the NG tube – Repositioning the tube is necessary if there is displacement, but it does not treat dehydration caused by hyperosmolar feedings.

C. Increase the rate of formula delivery – Increasing the rate can worsen dehydration by further increasing the solute load, leading to a greater fluid shift from intracellular to extracellular spaces.

D. Add water to the formula – This is the correct answer because hyperosmolar dehydration occurs when high-solute enteral formulas pull water into the intestines, leading to excessive fluid loss. To prevent this, the nurse should ensure the client receives adequate free water flushes alongside tube feedings.

A. Respite care B. Skilled nursing facility C. Rehabilitation services D. Assisted living

Correct Answer is A

Explanation

A. Respite care – This is the correct answer. Respite care provides temporary relief to caregivers by offering short-term professional care for the client, allowing the caregiver to rest and prevent burnout.

B. Skilled nursing facility – A skilled nursing facility is for long-term or intensive medical care needs, not temporary relief for a caregiver.

C. Rehabilitation services – Rehabilitation focuses on the client’s recovery, not the caregiver’s need for rest.

D. Assisted living – Assisted living is for clients needing ongoing assistance with daily activities, not temporary relief for a caregiver.

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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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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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