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1) A post-surgical client is unresponsive to painful stimuli and is given naloxone.

Within 5
minutes, the client is arousable and responds to verbal commands. One hour later, the
client is again difficult to arouse, with minimal response to physical stimuli. Which
actions should the nurse take? Select all that apply.
1. Administer oxygen
2. Assess respiratory rate
3. Initiate rapid response or code team
4. Notify the health care provider
5. Prepare a second dose of naloxone

Explanation:

A client in the post-operative period that is unresponsive to painful stimuli is likely still under
the effects of medications used during anesthesia. Using the opioid antagonist naloxone
(Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the
half-life of naloxone is much shorter than most opioid medications, wearing off in 1–2
hours. The nurse should make repeat assessments of the post-surgical client's respiratory
rate and administer prescribed oxygen for respiratory support. The health care provider
should be notified and a second dose of naloxone should be prepared and administered as
prescribed (either as a one-time dose or a continuous drip, depending on the prescription).
(Option 3) An overly sedated client is not an indication for a rapid response team. Although
this intervention is unlikely to cause harm to the client, it is not necessary and may result in
overuse of personnel resources. If additional information indicates a more serious situation
(eg, respiratory rate <8 breaths/min, oxygen saturation <90%), it may be appropriate to initiate
the emergency response system.
Educational objective:
Naloxone (Narcan) is usually prescribed as needed for post-surgical clients for over-sedation
related to opioid use. The nurse should continue to monitor clients who are given naloxone
with the understanding that the opioid antagonist has a shorter half-life than most of the
opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.
2) The postoperative client on hydromorphone becomes hypoxic, and naloxone is
administered per protocol. What is most important for the nurse to consider in the
follow-up care of this client?
1. Client's respiratory status 60 minutes later
2. Documenting the client's hypoxic event
3. Obtaining an order for a different analgesic
4. Potential for drug-drug interaction now

Explanation:

Hydromorphone duration of action is 3-4 hours. The effects of naloxone (Narcan) start to
wane at 20-40 minutes after administration, and its duration of action is approximately 90
minutes. Therefore, depending on the hydromorphone dose, its duration of action can
continue beyond the duration of the naloxone. Repeat naloxone doses may be necessary.
(Option 2) Documentation is essential, but client care is more important than paperwork.
(Option 3) Naloxone will reverse the effects of the narcotic in the body and, as long as it is in
the body, will reverse the effects of any additional narcotic administered. This client will need
a different class of analgesic at this time. However, adequate respiration/oxygenation as the
naloxone wears off is more important.
(Option 4) Naloxone is the reversal agent for narcotics, and a drug-drug interaction is not a
concern.
Educational objective:
The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to
reverse the effects of narcotics, the nurse must monitor the client to ensure that the client
does not fall again into excessive sedation and/or respiratory depression.
3) A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse
suspects the client has developed urinary retention. What is the priority nursing
intervention?
1. Ask if the client needs to use the bedpan
2. Assess the client's fluid intake
3. Assess the client's skin turgor
4. Palpate the client's suprapubic area

Explanation:

Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can
cause urinary retention; they increase bladder sphincter tone and/or relax bladder
muscle. The nurse should assess the client's suprapubic area to determine if the client has
urinary retention. If the area is distended and dull to percussion, the nurse should proceed
with interventions.
(Option 1) While asking if a bedpan is needed is an important nursing intervention, it does
not aid in the assessment of urinary retention.
(Option 2) Gathering assessment data indicating the presence of urinary retention is
necessary prior to other interventions. The nurse should assess for fluid intake after
assessing bladder distension.
(Option 3) The client's skin turgor is assessed after the nurse checks for urinary retention
and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid
intake are reviewed.
Educational objective:
Assessing the client's suprapubic area is the priority nursing action when urinary retention is
suspected. Interventions are performed after a problem is identified and its cause is
determined. Urinary retention is an expected side effect of opioid medications.
4) The nurse is administering IV hydromorphone to a client every 3-4 hours as needed for postoperative
pain. Which interventions should the nurse implement? Select all that apply.
1. Administer IV hydromorphone over 5-10 seconds
2. Administer PRN stool softener with daily medications
3. Hold hydromorphone if client is not practicing deep breathing exercises
4. Perform reassessment an hour after administration
5. Tell the client to call for assistance before getting out of bed

Explanation:
Opioid analgesics (eg, hydromorphone, morphine) are effective for controlling moderate to severe
pain. Major side effects include sedation, respiratory depression, hypotension, and constipation. The
client is at risk for falls from sedation or hypotension and should not get out of bed unassisted (Option
5). Slowed bowel motility persists throughout opioid use, and measures to prevent constipation (eg,
administration of daily stool softeners) should be implemented (Option 2).
(Option 1) IV hydromorphone should be administered slowly over 2-3 minutes. Rapid IV administration of
opioid analgesics can cause severe hypotension and respiratory or cardiac arrest.
(Option 3) Postoperative clients may experience pain with breathing exercises (eg, turning, coughing, deep
breathing, incentive spirometry). Uncontrolled postoperative pain may cause clients to avoid deep breathing
and lead to atelectasis and pneumonia. The nurse should administer opioids to achieve adequate pain control
as needed to encourage participation in postoperative exercises and prevent complications.
(Option 4) The nurse should reassess pain and sedation level during the opioid's peak effect, which is 15-30
minutes after administration of IV hydromorphone.
Educational objective:
Opioid analgesics are effective for managing postoperative pain, which encourages participation in deep
breathing exercises. Side effects of opioid analgesics include sedation, respiratory depression, hypotension,
and constipation. The nurse should administer IV hydromorphone slowly over 2-3 minutes, monitor sedation
level, instruct the client not to get out of bed unassisted, and administer PRN stool softeners.

Pasero opioid-induced sedation scale

Level of sedation Nursing intervention

 No action necessary
S – Sleeping, easy to rouse

 No action necessary
1 – Awake, alert  May increase sedation

 Acceptable, no action necessary


2 – Slightly drowsy but easy to rouse

 Unacceptable
 Monitor respiratory status
3 – Falls asleep during conversation  Notify health care provider to decrease sedation
by 25%-50%

 Stop sedation
 Consider using naloxone
4 – Somnolent, minimal or no response to verbal &
 Notify health care provider
physical stimuli
 Monitor respiratory status
5) A client with cancer pain is prescribed oxycodone. Which teaching is most essential
to help prevent long-term complications?
1. Teach the client how to assess blood pressure daily
2. Teach the client how to prevent constipation
3. Teach the client how to prevent itching
4. Teach the client how to prevent nausea

Explanation:

Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors


in the intestine, which slows peristalsis and increases water absorption, leading
to constipation. Constipation is an almost universally expected side effect from opioid
medications. Clients will not develop tolerance to this side effect. Although clients with
idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced
constipation is treated with simultaneous use of senna (stimulant) and docusate(stool
softener).
(Options 1 and 3) Opioids cause the release of histamine, a vasodilator, which is
responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and
nervous system depression; both can lead to hypotension. These develop in some clients
when the treatment is initiated but usually resolve over time. Antihistamines (eg,
diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated
position) and adequate hydration can prevent hypotension.
(Option 4) Opioids stimulate the opioid receptors in the gastrointestinal tract and the
chemoreceptor trigger zone in the brain, producing nausea. This is also not seen with long-
term use. Antiemetics (eg, ondansetron) can be helpful.
Educational objective:
Constipation is an expected long-term side effect of opioid use; clients will not develop
tolerance to this side effect. It is important to teach aggressive preventive measures (eg,
defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and
simultaneous use of a stool softener and a stimulant.
6) The nurse reviews an elderly client's medication administration record and identifies
which prescriptions as having the potential for injury in the elderly? Select all that
apply.
1. Amitriptyline
2. Chlorpheniramine
3. Docusate
4. Donepezil
5. Lorazepam

Explanation:

Polypharmacy and physiologic changes associated with aging (eg, decreased renal and
hepatic function, orthostatic hypotension, decreased visual acuity, balance and gait problems)
place the elderly at increased risk of adverse drug effects.
The Beers criteria provide a list that classifies potentially harmful drugs to avoid or
administer with caution in the elderly due to the high incidence of drug-induced toxicity,
cognitive dysfunction, and falls. Some commonly used medications in this list
include antipsychotics, anticholinergics, antihistamines, antihypertensives,
benzodiazepines, diuretics, opioids, and sliding insulin scales.
Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic
pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and
dysrhythmias (Option 1).
Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy
symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur
due to its reduced clearance in the elderly (Option 2).
Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects
include drowsiness, dizziness, ataxia, and confusion (Option 5).
(Option 3) Docusate is a stool softener and does not increase risk of injury in the elderly.
(Option 4) Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer
dementia. It does not place the elderly at increased risk of adverse effects.
Educational objective:
The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer
with caution in the elderly due to the high incidence of adverse effects and potential for
injury. The list includes antipsychotics, anticholinergics, antihistamines, antihypertensives,
benzodiazepines, diuretics, opioids, and sliding insulin scales.
7) A client recovering from femoral-popliteal bypass surgery performed yesterday reports
a pain level of 5 on a 0-10 scale. At 2400, the night shift nurse reviews the client's
medication administration record, shown in the exhibit. Which medication should the
nurse administer? Click on the exhibit button for additional information.
1. Acetaminophen
2. Alprazolam
3. Hydrocodone/acetaminophen
4. Morphine

Medication administration record


Allergies: None
Medications 0701-1500 1501-2300
Acetaminophen: 325 mg, 1-2 tablets orally, every 4-6
hours as needed
Alprazolam: 0.25 mg orally, every 6 hours as needed
Hydrocodone/acetaminophen: 5 mg/325 mg, 1-2 tablets
1900
orally, every 4-6 hours as needed
Morphine: 2 mg IV push, every 4 hours as needed 1400
Ondansetron: 4 mg IV push every 4 hours as needed 1600

Explanation:

The client is reporting a moderate level of pain. The medication administration record
indicates that the client last received hydrocodone/acetaminophen 5 hours ago. It is
reasonable for the nurse to choose the oral pain medication for moderate-level pain as the
client last received it and then did not require IV pain medication after that administration.
(Option 1) The pain level is too high for acetaminophen alone.
(Option 2) Alprazolam is typically used for the treatment of anxiety.
(Option 4) Morphine is indicated for severe pain.
Educational objective:
The nurse should administer an opioid analgesic to a client who is experiencing moderate-
level postoperative pain. Oral medication is an appropriate choice when it has been effective
previously.
8) During shift report it was noted that the off-going nurse had given the client a PRN dose
of morphine 2 mg every 2 hours for incisional pain. What current client assessment
would most likely affect the oncoming nurse's decision to discontinue the
administration every 2 hours?
1. Client reports burning during injection into the IV line
2. Client reports dizziness when getting up to use the bathroom
3. Client's blood pressure is 106/68 mm Hg
4. Client's respiratory rate is 11/min

Explanation:

Morphine is an opioid analgesic that can be given intravenously for moderate to severe
pain. An adverse reaction to morphine administration is respiratory
depression. A respiratory rate <12/min would be a reason to hold morphine
administration. The nurse should perform a more in-depth assessment of the client's pain
and causes. The morphine dose may need to be decreased or the time between
administrations may need to be increased. The nurse should not administer additional doses
until the respiratory rate increases.
(Option 1) Morphine can cause burning during IV administration. This can be reduced by
diluting the morphine with normal saline and administering it slowly over 4-5 minutes.
(Option 2) The nurse should instruct the client to call for help before getting up to go to use
the bathroom to avoid falls caused by dizziness from the morphine.
(Option 3) Morphine can lower blood pressure, and clients receiving it should have blood
pressure monitored. This blood pressure reading is not severely low and is not a priority over
the respiratory depression.
Educational objective:
Morphine administration can cause respiratory depression. The nurse should hold a dose of
morphine for a client whose respiratory rate is <12/min.
9) Which client is at greatest risk for respiratory depression when receiving opioids for
pain control?
1. 20-year-old client with bronchitis receiving inhaled bronchodilator therapy every 4 hours
2. 30-year-old client with heroin addiction with rotator cuff repair surgery this morning
3. 50-year-old client with sleep apnea and left foot cellulitis and scheduled for a bone scan
4. 70-year-old client with chronic obstructive pulmonary disease (COPD) with knee replacement thi

Explanation:

The following are at greatest risk for respiratory depression related to opioid use for
analgesia: the elderly; those with underlying pulmonary disease, history of snoring (with or
without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve,
especially if treated for acute pain; and post surgery (first 24 hours).
The 70-year old client has 3 significant risk factors: advanced age, COPD, and surgery within
24 hours. COPD clients who have hypercarbia and hypoxemia are at even greater risk for
respiratory depression when receiving opioids.
(Option 1) This client has 1 risk factor, pulmonary disease.
(Option 2) This client has 1 risk factor, surgery within 24 hours. His addiction to heroin gives
him a higher tolerance for opioids.
(Option 3) This client has 1 risk factor, sleep apnea.
Educational objective:
Factors that increase risk for respiratory depression related to opioid use for pain control
include advanced age, underlying pulmonary disease, snoring, obesity, smoking, opiate
naïve, and surgery.
10) The nurse admits a client to the unit who reports taking high doses of aspirin to
ease the pain of chronic headaches. The nurse should monitor for which adverse
effects? Select all that apply.
1. Black tarry stools
2. Bradycardia
3. Bruising
4. Hypertension
5. Ringing in the ears

Explanation:

Aspirin is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can


cause gastrointestinal (GI) bleeding by decreasing the production of prostaglandins, which
protect the lining of the stomach and intestines from digestive acids. NSAIDs (especially
aspirin) also decrease platelet aggregation and thereby inhibit blood clotting. Coffee-ground
emesis and black tarry stools (melena) are signs of GI bleeding. Bruising can occur due to
the decreased platelet aggregation. Tinnitus (ringing in the ears) is the earliest sign of
aspirin toxicity.
(Options 2 and 4) An NSAID overdose will cause tachycardia (not bradycardia) and
hypotension (not hypertension). However, tachycardia and hypotension occur later,
secondary to blood loss and dehydration due to nausea and vomiting (common side effects).
Educational objective:
Aspirin and other NSAIDs inhibit platelet aggregation, resulting in GI bleeding
complications. They also promote development of gastric ulcers with long-term use. Tinnitus
(ringing in the ears) is the earliest sign of aspirin toxicity.