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 D

Explanation

A. Fold the stockings at the top if they are too long – Folding the stockings can create a tourniquet effect, restricting circulation and increasing the risk of complications.

B. Remove the stockings every 24 hr – Antiembolitic stockings should be removed at least every 8 hr to assess skin integrity and circulation, not just once per day.

C. Massage the legs before applying the stockings – Massaging the legs is contraindicated in clients with DVT because it can dislodge a clot, leading to a pulmonary embolism.

D. Measure the legs with a tape measure to determine stocking size – This is the correct action because improper fit can reduce effectiveness or impair circulation. The nurse should measure the client’s legs and select the appropriate size for optimal compression.

A. Placental abruption B. Amniotic fluid embolus C. Placenta previa D. Uterine rupture

Correct Answer is A

Explanation

A. Placental abruption – This is the correct answer because placental abruption occurs when the placenta detaches prematurely from the uterine wall, leading to severe abdominal pain, vaginal bleeding, uterine rigidity, and signs of hypovolemic shock (low blood pressure). The hallmark sign is a painful, rigid abdomen with contractions.

B. Amniotic fluid embolus – This condition presents with sudden respiratory distress, hypotension, and disseminated intravascular coagulation (DIC), but it does not typically cause uterine rigidity or persistent contractions.

C. Placenta previa – Placenta previa typically presents with painless vaginal bleeding rather than severe abdominal pain and a rigid uterus.

D. Uterine rupture – Uterine rupture is usually associated with a history of uterine surgery (e.g., previous cesarean section). It presents with sudden, severe pain followed by cessation of contractions, not persistent contractions.

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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 deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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