Nclexrn Quiz: Substance Use And Withdrawal Care
20 questions · exam conditions
0:00
Substance Use And Withdrawal CareQuestion 1 of 20

A 50-year-old client admitted for surgery has a history of alcohol use disorder and last drank 36 hours ago. The client is confused, has severe tremors, and is pulling at intravenous lines; vital signs: temperature 38.1°C (100.6°F), heart rate 134/min, blood pressure 190/112 mm Hg, respiratory rate 28/min; mental status: disoriented with visual hallucinations; labs: potassium 3.0 mEq/L (normal 3.5–5.0). Which intervention should the nurse implement IMMEDIATELY?

Place the client on continuous cardiac and pulse oximetry monitoring, initiate seizure precautions, and administer prescribed benzodiazepine per protocol
Provide extensive education about Alcoholics Anonymous meeting schedules
Request a prescription for nicotine gum to address restlessness
Collect a detailed dietary recall to address electrolyte abnormalities
← Back to quizzes

Nclexrn Quiz

Nclexrn Quiz: Substance Use And Withdrawal Care

Practice Substance Use And Withdrawal Care in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Substance Use And Withdrawal Care, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

A 50-year-old client admitted for surgery has a history of alcohol use disorder and last drank 36 hours ago. The client is confused, has severe tremors, and is pulling at intravenous lines; vital signs: temperature 38.1°C (100.6°F), heart rate 134/min, blood pressure 190/112 mm Hg, respiratory rate 28/min; mental status: disoriented with visual hallucinations; labs: potassium 3.0 mEq/L (normal 3.5–5.0). Which intervention should the nurse implement IMMEDIATELY?

  1. Place the client on continuous cardiac and pulse oximetry monitoring, initiate seizure precautions, and administer prescribed benzodiazepine per protocol (correct answer)
  2. Provide extensive education about Alcoholics Anonymous meeting schedules
  3. Request a prescription for nicotine gum to address restlessness
  4. Collect a detailed dietary recall to address electrolyte abnormalities
Explanation: This question tests nursing interventions and clinical judgment related to substance use, addressing delirium tremens in alcohol withdrawal. The priority concern is the client's confusion, severe tremors, hallucinations, fever, tachycardia, hypertension, and hypokalemia, indicating high mortality risk. Placing on monitoring, seizure precautions, and administering benzodiazepines is the best choice as it stabilizes autonomic hyperactivity, referencing vital signs and disorientation. AA education is long-term; nicotine gum irrelevant; dietary recall secondary. The underlying principle of care in substance use scenarios is aggressive symptom management to prevent seizures and cardiovascular collapse. Electrolyte replacement supports recovery. A transferable nursing strategy is to orient frequently and reduce stimuli in hallucinating clients.

Question 2

A 40-year-old client admitted for abdominal pain has a history of alcohol use disorder and last drank 6 hours ago. The client is anxious with mild tremors; vital signs: heart rate 102/min, blood pressure 150/86 mm Hg; mental status: oriented; labs: glucose 56 mg/dL (normal 70–110). Which assessment finding requires IMMEDIATE attention?

  1. Glucose 56 mg/dL (normal 70–110) (correct answer)
  2. Mild tremors and anxiety
  3. Blood pressure 150/86 mm Hg
  4. History of alcohol use disorder
Explanation: This question tests nursing interventions and clinical judgment related to substance use, addressing acute complications in alcohol use disorder. The priority concern is the client's anxiety, mild tremors, tachycardia, hypertension, and hypoglycemia, with risk for seizures or altered mental status. The glucose of 56 mg/dL requires immediate attention as alcoholics are prone to hypoglycemia, exacerbating withdrawal. Tremors and anxiety are expected; blood pressure elevated but secondary; history not acute. The underlying principle of care in substance use scenarios is correcting metabolic derangements promptly. Glucose administration follows thiamine to prevent encephalopathy. A transferable nursing strategy is to check blood glucose routinely in withdrawing clients and treat per protocol.

Question 3

A 52-year-old client admitted for pancreatitis reports drinking "a fifth of vodka daily" for years and had the last drink 10 hours ago. The client is diaphoretic and anxious with coarse tremors, nausea, and insomnia; vital signs: temperature 37.2°C (99.0°F), heart rate 118/min, blood pressure 176/98 mm Hg, respiratory rate 22/min, oxygen saturation 97% on room air; mental status: oriented but restless and easily startled; labs: magnesium 1.3 mg/dL (normal 1.7–2.2), potassium 3.2 mEq/L (normal 3.5–5.0). Which intervention should the nurse implement IMMEDIATELY for this client?

  1. Request a prescription for disulfiram and provide medication teaching
  2. Administer naloxone and prepare for rapid sequence intubation
  3. Obtain a detailed timeline of alcohol intake and complete a full substance-use screening tool
  4. Institute seizure precautions and administer the prescribed benzodiazepine per alcohol-withdrawal protocol (correct answer)
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically recognizing and managing alcohol withdrawal syndrome. The priority concern is the client's symptoms of diaphoresis, anxiety, tremors, nausea, insomnia, tachycardia, hypertension, and electrolyte imbalances, indicating severe alcohol withdrawal with risk for seizures and delirium tremens. Instituting seizure precautions and administering benzodiazepines per protocol is the best choice because the client's elevated heart rate, blood pressure, and low magnesium and potassium levels increase seizure risk, requiring immediate stabilization. Requesting disulfiram is incorrect as it is for aversion therapy post-detox, not acute withdrawal; obtaining a timeline is important but not immediate; naloxone is for opioids, not alcohol, which is a common misconception in mixed substance cases. The underlying principle of care in substance use scenarios is to prioritize physiological stability and prevent life-threatening complications like seizures or cardiovascular events. Additionally, electrolyte correction and thiamine administration are essential to avoid Wernicke-Korsakoff syndrome. A transferable nursing strategy is to use standardized tools like CIWA-Ar for ongoing assessment and symptom-triggered interventions in withdrawal management.

Question 4

A 36-year-old client on a psychiatric unit has a history of methamphetamine use and has not slept for 2 days. The client is diaphoretic, has jaw clenching, and is yelling that staff are "trying to poison me"; vital signs: temperature 38.6°C (101.5°F), heart rate 140/min, blood pressure 174/110 mm Hg, respiratory rate 28/min; mental status: paranoid, escalating agitation; labs: potassium 4.0 mEq/L (normal 3.5–5.0). Which assessment finding requires IMMEDIATE attention?

  1. Temperature 38.6°C (101.5°F) with severe agitation and tachycardia (correct answer)
  2. Report of not sleeping for 2 days
  3. Potassium 4.0 mEq/L within normal range
  4. Client statement that staff are "trying to poison me"
Explanation: This question tests nursing interventions and clinical judgment related to substance use, identifying critical signs in stimulant intoxication. The priority concern is the client's insomnia, diaphoresis, jaw clenching, paranoia, fever, tachycardia, and hypertension, signaling severe toxicity. The temperature of 38.6°C with agitation and tachycardia requires immediate attention as it indicates hyperthermia and risk for cardiac arrhythmia or rhabdomyolysis. Insomnia is expected; normal potassium is not urgent; paranoia is concerning but secondary to vital sign instability. The underlying principle of care in substance use scenarios is to address hyperadrenergic crises promptly to prevent organ damage. Cooling measures and benzodiazepines may be needed. A transferable nursing strategy is to monitor for dehydration and electrolyte shifts in prolonged stimulant use.

Question 5

A 60-year-old client admitted for gastrointestinal bleeding has a history of alcohol use disorder and reports the last drink was 18 hours ago. The client is increasingly confused and has visual hallucinations of "bugs on the wall"; vital signs: temperature 38.3°C (100.9°F), heart rate 126/min, blood pressure 188/104 mm Hg, respiratory rate 26/min; mental status: disoriented, severe agitation; labs: sodium 132 mEq/L (normal 135–145). Which assessment finding requires IMMEDIATE attention?

  1. Blood pressure 188/104 mm Hg with new-onset hallucinations and disorientation (correct answer)
  2. Sodium 132 mEq/L with mild headache
  3. History of alcohol use disorder for more than 10 years
  4. Client reports poor sleep since admission
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically identifying severe alcohol withdrawal complications. The priority concern is the client's confusion, visual hallucinations, agitation, fever, tachycardia, hypertension, and hyponatremia, suggesting delirium tremens. The blood pressure of 188/104 mm Hg with hallucinations requires immediate attention as it indicates autonomic hyperactivity and risk for stroke or seizures. Mild hyponatremia with headache is less urgent; long history is a risk factor but not acute; poor sleep is common but not critical. The underlying principle of care in substance use scenarios is to recognize escalating symptoms like delirium for prompt intervention. Benzodiazepines and supportive care are key to prevent mortality. A transferable nursing strategy is to monitor vital signs frequently and use scales like CIWA-Ar to guide treatment in withdrawal.

Question 6

A 31-year-old client is brought to the emergency department after suspected fentanyl use. The client is cyanotic with respiratory rate 5/min, oxygen saturation 80% on room air, heart rate 58/min, blood pressure 104/60 mm Hg; pupils are pinpoint; mental status: unresponsive to voice. Which intervention should the nurse implement IMMEDIATELY for this client?

  1. Start intravenous fluids at a keep-vein-open rate and wait for the provider to evaluate the client
  2. Place the client in a low-stimulation environment and encourage sleep
  3. Obtain consent for substance-use treatment and initiate referral paperwork
  4. Administer naloxone per protocol and provide ventilatory support while preparing for possible repeat dosing (correct answer)
Explanation: This question tests nursing interventions and clinical judgment related to substance use, responding to opioid overdose. The priority concern is the client's cyanosis, bradypnea, hypoxia, bradycardia, hypotension, pinpoint pupils, and unresponsiveness, indicating severe respiratory depression. Administering naloxone with ventilatory support is the best choice as it reverses effects quickly, addressing the low saturation and rate. IV fluids alone ignore reversal; consent delays emergency care; low stimulation is insufficient for apnea. The underlying principle of care in substance use scenarios is rapid antidote administration in life-threatening overdoses. Preparation for intubation may be needed if no response. A transferable nursing strategy is to train laypersons in naloxone use for community overdose prevention.

Question 7

A 45-year-old client admitted for cellulitis has a history of alcohol use disorder and last drank 24 hours ago. The client is tremulous and anxious; vital signs: heart rate 108/min, blood pressure 154/88 mm Hg, respiratory rate 20/min, oxygen saturation 98% on room air; mental status: oriented; labs: magnesium 1.4 mg/dL (normal 1.7–2.2). Which intervention should the nurse implement IMMEDIATELY to reduce risk of complications?

  1. Request an order for naloxone to keep at the bedside for withdrawal symptoms
  2. Encourage the client to ambulate in the hallway to reduce anxiety
  3. Obtain a detailed family history of substance use disorders
  4. Administer thiamine as prescribed before giving glucose-containing fluids or nutrition (correct answer)
Explanation: This question tests nursing interventions and clinical judgment related to substance use, preventing complications in alcohol withdrawal. The priority concern is the client's tremors, anxiety, tachycardia, hypertension, and hypomagnesemia, with risk for Wernicke's encephalopathy. Administering thiamine before glucose is the best choice as it prevents neurological damage, supported by the vital signs and low magnesium. Ambulation increases fall risk; family history is not immediate; naloxone is for opioids. The underlying principle of care in substance use scenarios is nutritional supplementation to counter deficiencies from chronic alcohol use. Benzodiazepines address symptoms separately. A transferable nursing strategy is to routinely give thiamine, folate, and multivitamins in alcohol use disorder admissions.

Question 8

A 39-year-old client on a psychiatric unit has a history of methamphetamine use and is now refusing care, shouting, and throwing objects. Vital signs: heart rate 128/min, blood pressure 160/96 mm Hg, respiratory rate 22/min, oxygen saturation 98% on room air; mental status: alert, hostile, paranoid; labs: none yet. What is the FIRST action the nurse should take for this client?

  1. Offer nicotine patch therapy to reduce agitation
  2. Ask security to apply restraints immediately without further assessment
  3. Complete a full head-to-toe physical assessment before addressing behavior
  4. Attempt verbal de-escalation, ensure adequate staff support, and maintain a safe distance with an exit route (correct answer)
Explanation: This question tests nursing interventions and clinical judgment related to substance use, de-escalating stimulant-induced agitation. The priority concern is the client's refusal of care, shouting, throwing objects, tachycardia, hypertension, hostility, and paranoia, posing safety risks. Attempting verbal de-escalation with staff support and safe positioning is the best choice as it prevents escalation, per the vital signs and behavior. Immediate restraints bypass least-restrictive options; full assessment risks safety; nicotine patch is unrelated. The underlying principle of care in substance use scenarios is non-confrontational approaches in psychotic states. Medications like antipsychotics may follow if needed. A transferable nursing strategy is to document behaviors and interventions for legal protection in behavioral crises.

Question 9

A 28-year-old client presents to the emergency department after opioid use; the client is awake but very sleepy. Vital signs: respiratory rate 10/min, oxygen saturation 91% on room air, heart rate 66/min, blood pressure 118/72 mm Hg; pupils are pinpoint; mental status: responds to voice. Which intervention should the nurse implement IMMEDIATELY?

  1. Request a nicotine patch prescription for the client's sedation and schedule an outpatient counseling session
  2. Provide in-depth counseling about medication-assisted treatment options and schedule a follow-up appointment with an addiction specialist for tomorrow
  3. Obtain a comprehensive social and housing history to determine the client's support system and plan for safe discharge
  4. Apply supplemental oxygen, stimulate the client, and prepare to administer naloxone per protocol if respirations decline further (correct answer)
Explanation: The client's presentation—bradypnea, hypoxemia, pinpoint pupils, and depressed mental status—indicates opioid intoxication with a risk of progression to respiratory arrest. The immediate priority is to support ventilation and prevent further decline. Applying supplemental oxygen raises oxygen saturation, stimulating the client (e.g., sternal rub) may increase respiratory drive, and preparing naloxone allows rapid reversal if respirations fall further. These actions directly address the life-threatening risk. Requesting a nicotine patch is incorrect because nicotine is not an opioid antagonist and does not treat opioid-induced sedation; it also delays urgent care. Counseling about medication-assisted treatment and scheduling follow-up is important for long-term management but does not address the current respiratory depression. Obtaining a social history, while relevant for discharge planning, is non-urgent and does not stabilize the client's airway or breathing. Therefore, the only intervention meeting the 'immediate' requirement is the one that provides oxygen, stimulation, and readiness for naloxone.

Question 10

A 44-year-old client in a community clinic reports quitting smoking 1 week ago after smoking 1.5 packs/day for 25 years. The client reports cravings and weight gain; vital signs: blood pressure 128/80 mm Hg, heart rate 78/min; mental status: motivated but frustrated; labs: none abnormal. Which intervention should the nurse implement IMMEDIATELY?

  1. Teach coping strategies for cravings and offer nicotine replacement therapy options such as patch plus short-acting gum or lozenge (correct answer)
  2. Administer naloxone 0.4 mg intravenously and observe the client for opioid withdrawal symptoms for the next hour
  3. Institute seizure precautions for the first 72 hours after quitting smoking and reassess neurologic status at 2-hour intervals
  4. Request a prescription for a short-acting benzodiazepine and schedule follow-up to reduce cravings and to prevent smoking relapse during the first weeks
Explanation: At 1 week after stopping a long heavy smoking habit, the priority is to prevent relapse while the client is still motivated. Teaching coping strategies and offering nicotine replacement therapy, such as a patch plus short-acting gum or lozenge, is the evidence-based immediate intervention; it controls cravings and supports behavioral change. Administering naloxone and observing for opioid withdrawal is incorrect because naloxone is an opioid antagonist and the client has no evidence of opioid exposure; it does not treat nicotine withdrawal. Instituting seizure precautions is incorrect because nicotine withdrawal does not produce a seizure risk; this concern belongs to alcohol or sedative withdrawal. Requesting a benzodiazepine and scheduling follow-up is incorrect because benzodiazepines are not first-line for nicotine cravings and do not prevent smoking relapse; they add dependence risk. The best immediate action is behavioral support combined with NRT.

Question 11

A 27-year-old client arrives to the emergency department after an opioid overdose reversed by emergency medical services. The client is now awake but drowsy; vital signs: respiratory rate 14/min, oxygen saturation 96% on room air, heart rate 104/min, blood pressure 138/82 mm Hg; pupils no longer pinpoint; mental status: anxious and nauseated; labs: none available yet. Which intervention should the nurse implement IMMEDIATELY for this client?

  1. Initiate seizure precautions because anxiety, nausea, and tachycardia may represent alcohol withdrawal in this overdose patient.
  2. Collect a complete substance-use history and administer a depression screening tool to identify possible underlying reasons for the overdose.
  3. Request a prescription for methadone and administer the first dose immediately to reduce withdrawal and prevent a repeat overdose.
  4. Provide continuous respiratory and oxygen saturation monitoring and reassess for recurrent sedation as naloxone wears off. (correct answer)
Explanation: After an opioid overdose is reversed with naloxone, the client remains at risk for recurrent sedation because the opioid may remain in the body longer than the reversal agent. The immediate priority is continuous respiratory and oxygen saturation monitoring with frequent reassessment of sedation. Seizure precautions are not supported here: there is no evidence of alcohol withdrawal, and the anxiety, nausea, and tachycardia after naloxone are more consistent with opioid withdrawal than with alcohol withdrawal. Collecting a complete substance-use history and administering a depression screen may be useful later, but it is not the urgent step and does not address the risk of renewed respiratory depression. Starting methadone immediately is also incorrect because methadone is a long-term treatment for opioid use disorder, not an emergency post-reversal intervention; giving it before the client is observed may make sedation harder to monitor. Only continuous respiratory monitoring and repeated sedation assessment directly address the risk that naloxone will wear off before the opioid is cleared.

Question 12

A 23-year-old client presents to a community clinic 24 hours after stopping cigarettes (1 pack/day for 6 years). The client reports irritability, increased appetite, and cravings; vital signs: blood pressure 124/76 mm Hg, heart rate 82/min; mental status: frustrated but motivated to quit; labs: none abnormal. What is the FIRST action the nurse should take for this client?

  1. Assess nicotine dependence and contraindications, then collaborate with the client to select an appropriate nicotine replacement option (correct answer)
  2. Administer a benzodiazepine as needed to relieve withdrawal-related irritability until the client can begin nicotine replacement therapy
  3. Obtain a blood alcohol level to rule out alcohol withdrawal as the cause of the client's cravings, increased appetite, and irritability
  4. Request a prescription for disulfiram to support the client's smoking withdrawal and arrange follow-up counseling for relapse prevention
Explanation: At 24 hours after stopping cigarettes, the client's irritability, increased appetite, and cravings are classic nicotine withdrawal symptoms. Vital signs and labs are normal, and the client is motivated, so the first action is to assess nicotine dependence and contraindications, then collaborate with the client on an appropriate nicotine replacement option. This directly addresses the cause and personalizes treatment. Administering a benzodiazepine is not a first-line treatment for nicotine withdrawal; it only suppresses irritability and adds an unnecessary medication risk. Obtaining a blood alcohol level does not help because there is no indication of alcohol use, and a blood alcohol level cannot diagnose or rule out alcohol withdrawal; it also delays the correct intervention. Requesting disulfiram is wrong because disulfiram is an alcohol-aversion medication and has no role in nicotine withdrawal or smoking cessation. Therefore, the assess-and-collaborate plan is the only best first action.

Question 13

A 46-year-old client is admitted for cellulitis and has a history of daily alcohol intake (1012 drinks/day); last drink was 8 hours ago. The client is anxious with fine tremors and reports nausea; vital signs: temperature 37.06 C (98.66 F), heart rate 112/min, blood pressure 162/96 mm Hg, respiratory rate 20/min; mental status: alert and oriented; labs: aspartate aminotransferase (AST) 98 U/L (normal 1040 U/L). Which intervention should the nurse implement IMMEDIATELY for this client?

  1. Continue routine vital signs every 8 hours because symptoms are mild
  2. Initiate a standardized alcohol-withdrawal assessment and administer prescribed medication based on the score (correct answer)
  3. Obtain a complete family history of substance use disorders
  4. Request a prescription for methadone to prevent withdrawal-related discomfort
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically early alcohol withdrawal requiring systematic assessment and treatment. The priority concern is that this client with heavy daily alcohol use is showing early withdrawal signs (anxiety, tremors, nausea, elevated vital signs) 8 hours after last drink, requiring immediate standardized assessment to guide medication administration and prevent progression. Initiating standardized withdrawal assessment and administering medication based on scores (B) is the best choice because it provides objective measurement of withdrawal severity and ensures appropriate benzodiazepine dosing to prevent complications. Continuing routine vital signs (A) dangerously underestimates withdrawal risks, obtaining family history (C) delays urgent treatment, and methadone (D) is for opioid not alcohol withdrawal. The underlying principle is that alcohol withdrawal severity can progress rapidly, and standardized assessment tools (like CIWA-Ar) guide evidence-based treatment to prevent seizures and delirium tremens. The transferable nursing strategy is to use validated withdrawal assessment tools immediately upon recognizing early symptoms, reassess frequently, and administer medications based on objective scores rather than subjective judgment.

Question 14

A 26-year-old client is brought to the emergency department after being found unresponsive; friends report heroin use. Assessment findings: respiratory rate 6/min with shallow respirations, oxygen saturation 82% on room air, heart rate 54/min, blood pressure 98/56 mm Hg; pupils are pinpoint; mental status: unresponsive to verbal stimuli; glucose 96 mg/dL (normal 70110 mg/dL). What is the FIRST action the nurse should take for this client?

  1. Administer naloxone per protocol and support ventilation as needed (correct answer)
  2. Obtain a urine drug screen before giving any medications
  3. Place the client in a quiet room and dim the lights to reduce stimulation
  4. Request a prescription for methadone to prevent withdrawal symptoms
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically opioid overdose management. The priority concern is respiratory depression (rate 6/min, O2 sat 82%) with classic opioid overdose signs (pinpoint pupils, unresponsiveness) requiring immediate reversal to prevent respiratory arrest and death. Administering naloxone and supporting ventilation (A) is the best choice because it directly reverses opioid-induced respiratory depression and restores adequate oxygenation within minutes. Obtaining a urine drug screen (B) wastes precious time when the clinical presentation is clear, placing in a quiet room (C) ignores the life-threatening respiratory depression, and methadone (D) would worsen the overdose as it's an opioid agonist, not an antagonist. The underlying principle is that opioid overdose causes potentially fatal respiratory depression that requires immediate reversal with naloxone, an opioid antagonist, while supporting ventilation. The transferable nursing strategy is to recognize the opioid overdose triad (respiratory depression, pinpoint pupils, decreased consciousness), administer naloxone immediately, and monitor for re-sedation as naloxone's duration is shorter than most opioids.

Question 15

A 28-year-old client arrives in the emergency department after receiving naloxone from emergency medical services for a suspected opioid overdose; the client reports taking "pain pills" purchased from a friend. Current assessment: respiratory rate 14/min, oxygen saturation 95% on room air, heart rate 106/min, blood pressure 142/86 mm Hg; pupils 3 mm and reactive; mental status: awake and anxious. Which assessment finding requires IMMEDIATE attention?

  1. The client reports generalized muscle aches and yawning
  2. Respiratory rate decreases to 8/min with oxygen saturation 88% on room air (correct answer)
  3. The client requests to leave the emergency department to go home
  4. The client reports nausea and abdominal cramping
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically post-naloxone monitoring after opioid overdose reversal. The priority concern is that the client's respiratory rate has decreased to 8/min with hypoxia (O2 sat 88%), indicating re-sedation as naloxone's effects wear off while longer-acting opioids remain in the system. Respiratory depression recurring after naloxone (B) requires immediate attention because it indicates opioid effects are outlasting the antagonist, risking respiratory arrest. Muscle aches and yawning (A) are expected opioid withdrawal symptoms from naloxone, requesting to leave (C) is concerning but not immediately life-threatening, and nausea/cramping (D) are also expected withdrawal symptoms. The underlying principle is that naloxone has a shorter duration (30-90 minutes) than most opioids, requiring continuous monitoring for re-sedation and potential need for repeat doses or continuous infusion. The transferable nursing strategy is to monitor post-naloxone patients closely for at least 2-4 hours, watching for return of respiratory depression, and being prepared to administer additional naloxone doses as needed.

Question 16

A 29-year-old client is brought to the emergency department after being found unresponsive with a syringe nearby; friends report heroin use. The client has shallow breathing with respiratory rate 6/min, oxygen saturation 84% on room air, heart rate 52/min, blood pressure 98/54 mm Hg, and pinpoint pupils; mental status: difficult to arouse, gurgling respirations; labs: arterial blood gas shows pH 7.22 (normal 7.35–7.45), PaCO2 62 mm Hg (normal 35–45). What is the FIRST action the nurse should take for this client?

  1. Place the client in a quiet room with dim lighting to reduce stimulation
  2. Collect a urine toxicology screen before initiating any treatment
  3. Request a prescription for buprenorphine-naloxone and begin induction teaching
  4. Administer naloxone immediately per protocol and support ventilation with a bag-valve mask (correct answer)
Explanation: This question tests nursing interventions and clinical judgment related to substance use, focusing on acute opioid overdose reversal. The priority concern is the client's unresponsiveness, shallow breathing, low oxygen saturation, bradycardia, hypotension, pinpoint pupils, and respiratory acidosis, signaling opioid-induced respiratory depression. Administering naloxone immediately and supporting ventilation is the best choice as it rapidly reverses opioid effects, addressing the life-threatening hypoventilation and low saturation. Collecting a urine toxicology screen delays care, which is a misconception that testing must precede treatment; buprenorphine is for maintenance, not acute overdose; a quiet room is unsuitable for respiratory compromise. The underlying principle of care in substance use scenarios is to ensure airway, breathing, and circulation stability first in overdoses. Supportive measures like oxygen and monitoring for renarcotization are crucial due to naloxone's short half-life. A transferable nursing strategy is to prepare for precipitated withdrawal and have repeat doses ready while educating on harm reduction.

Question 17

A 57-year-old client is admitted for pneumonia and has a history of alcohol use disorder (6 beers nightly); last drink was 12 hours ago. The client has mild tremors, nausea, headache, and anxiety; vital signs: temperature 37.46 C (99.36 F), heart rate 104/min, blood pressure 154/92 mm Hg, respiratory rate 18/min; mental status: alert and oriented; labs: glucose 70 mg/dL (normal 70110 mg/dL). What is the FIRST action the nurse should take for this client?

  1. Administer prescribed thiamine before giving glucose-containing fluids or nutrition (correct answer)
  2. Ask the provider to prescribe disulfiram to prevent relapse
  3. Obtain a repeat blood alcohol level to determine the severity of withdrawal
  4. Encourage the client to ambulate in the hallway to reduce anxiety
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically early alcohol withdrawal with risk for Wernicke's encephalopathy. The priority concern is that this client with chronic alcohol use is at high risk for thiamine deficiency, and administering glucose without thiamine first can precipitate Wernicke's encephalopathy, a medical emergency causing confusion, ataxia, and eye movement abnormalities. Administering thiamine before glucose (A) is the best choice because it prevents this irreversible neurological complication while addressing the borderline low glucose safely. Disulfiram (B) is contraindicated during withdrawal, repeat alcohol levels (C) don't guide withdrawal treatment, and encouraging ambulation (D) could be unsafe with potential ataxia and doesn't address the thiamine deficiency. The underlying principle is that chronic alcohol use depletes thiamine stores, and glucose administration increases thiamine demand, potentially triggering Wernicke's encephalopathy if thiamine isn't replaced first. The transferable nursing strategy is to always administer thiamine before or with glucose in any patient with alcohol use disorder, regardless of withdrawal severity, to prevent permanent neurological damage.

Question 18

A 19-year-old client is seen in a community clinic and reports vaping nicotine daily for 3 years; the client stopped 2 days ago. The client reports intense cravings, irritability, difficulty concentrating, and insomnia; vital signs: temperature 36.86 C (98.26 F), heart rate 92/min, blood pressure 128/78 mm Hg, respiratory rate 16/min; mental status: anxious but cooperative; labs: within expected limits. Which intervention should the nurse implement IMMEDIATELY for this client?

  1. Administer naloxone and monitor for recurrent respiratory depression
  2. Teach coping strategies and initiate nicotine replacement therapy per clinic protocol (correct answer)
  3. Obtain an electrocardiogram before discussing any treatment options
  4. Request a prescription for disulfiram to reduce nicotine cravings
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically nicotine withdrawal management. The priority concern is the client's nicotine withdrawal symptoms (cravings, irritability, insomnia, difficulty concentrating) that began 2 days after cessation, which can lead to relapse without appropriate support. Teaching coping strategies and initiating nicotine replacement therapy (B) is the best choice because it addresses withdrawal symptoms, reduces cravings, and supports successful cessation through evidence-based interventions. Naloxone (A) is for opioid overdose and irrelevant here, obtaining an ECG (C) is unnecessary with normal vital signs and no cardiac symptoms, and disulfiram (D) is for alcohol use disorder, not nicotine dependence. The underlying principle is that nicotine withdrawal, while not life-threatening, requires prompt symptom management and behavioral support to prevent relapse and promote successful cessation. The transferable nursing strategy is to recognize nicotine withdrawal symptoms, provide immediate coping strategies, initiate replacement therapy when appropriate, and offer ongoing support throughout the cessation process.

Question 19

A 29-year-old client on a psychiatric unit admits to using methamphetamine earlier today and becomes increasingly agitated. The client is sweating and clenching fists; vital signs: temperature 38.16 C (100.66 F), heart rate 140/min, blood pressure 172/104 mm Hg, respiratory rate 26/min; mental status: paranoid and threatening staff; labs: sodium 140 mEq/L (normal 135145 mEq/L). The nurse should PRIORITIZE which action for the client experiencing stimulant intoxication?

  1. Approach with a calm, nonthreatening stance, set clear limits, and call for assistance to maintain safety (correct answer)
  2. Begin motivational interviewing about readiness to stop using methamphetamine
  3. Ask the provider to prescribe disulfiram to reduce cravings
  4. Obtain a full sleep history and teach sleep hygiene strategies
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically acute methamphetamine intoxication with escalating aggression. The priority concern is the client's paranoid, threatening behavior with sympathetic overstimulation (tachycardia, hypertension, hyperthermia) creating immediate danger to self, staff, and other patients requiring de-escalation and safety measures. Approaching calmly, setting limits, and calling for assistance (A) is the best choice because it prioritizes safety while using therapeutic communication to prevent violence and prepare for potential physical intervention if needed. Starting motivational interviewing (B) is inappropriate during acute intoxication with paranoia, disulfiram (C) is for alcohol not stimulants, and teaching sleep hygiene (D) ignores the immediate safety threat. The underlying principle is that stimulant-induced paranoia and aggression require immediate safety interventions, including team response, before any therapeutic interventions can be attempted. The transferable nursing strategy is to maintain a calm demeanor, ensure adequate backup is available, use clear and simple communication, respect personal space, and be prepared to implement emergency protocols if verbal de-escalation fails.

Question 20

A 33-year-old client is brought to the emergency department for suspected opioid overdose after taking oxycodone with alcohol; the client has a history of opioid misuse. Assessment: respiratory rate 7/min, oxygen saturation 84% on room air, heart rate 48/min, blood pressure 90/50 mm Hg; pupils pinpoint; mental status: minimally responsive to painful stimuli; labs: arterial blood gas shows pH 7.28 (normal 7.3517.45), PaCO2 58 mm Hg (normal 35145 mm Hg). Which intervention should the nurse implement IMMEDIATELY for this client?

  1. Collect a urine specimen for toxicology screening before initiating treatment
  2. Administer naloxone per protocol and provide bag-valve-mask ventilation with supplemental oxygen (correct answer)
  3. Request a prescription for buprenorphine to begin maintenance therapy in the emergency department
  4. Place the client in a quiet, low-stimulation environment and reorient as needed
Explanation: This question tests nursing interventions and clinical judgment related to substance use, specifically severe opioid overdose with respiratory acidosis. The priority concern is profound respiratory depression (rate 7/min, O2 sat 84%) with respiratory acidosis (pH 7.28, PaCO2 58) indicating inadequate ventilation and imminent respiratory arrest requiring immediate reversal and ventilatory support. Administering naloxone and providing bag-valve-mask ventilation (B) is the best choice because it simultaneously reverses opioid effects and corrects hypoxemia/hypercapnia through assisted ventilation. Collecting urine for toxicology (A) delays life-saving treatment, starting buprenorphine (C) would worsen the overdose as it's a partial opioid agonist, and placing in a quiet environment (D) ignores the critical respiratory failure. The underlying principle is that severe opioid overdose with respiratory acidosis requires both pharmacological reversal with naloxone and mechanical ventilatory support to prevent death from hypoxic brain injury. The transferable nursing strategy is to recognize that severe respiratory depression may require ventilatory support beyond naloxone alone, especially when acidosis is present, and to provide assisted ventilation while administering the antidote.