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A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Opioid-Induced Sedation Scale score indicating excessive sedation and oxygen saturation below 95%. What action should the nurse perform first?
- A. Apply oxygen at 2 L/min
- B. Notify the provider immediately
- C. Administer naloxone (Narcan)
- D. Encourage deep breathing exercises
Correct Answer: C
Rationale: Excessive sedation and low oxygen saturation indicate opioid-induced respiratory depression. Administering naloxone (Narcan) is the first action to reverse opioid effects and ensure client safety. Applying oxygen or notifying the provider may follow, but naloxone is the priority. Encouraging deep breathing is insufficient in this scenario.
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A client is put on twice-daily acctantimopohen (Tylenol) for actoarthritis. What finding in the clients health history would lead the nurse to consult with the provider over the choice of medication?
- A. 2 Space-year smoking history
- B. Drinking in 5 beers to day
- C. Previous peptic ulcer
- D. Taking warfarin (Coumadin)
Correct Answer: B
Rationale: The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking, previous peptic ulcer, or warfarin use are not related to acetaminophen side effects.
A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?
- A. Bilateral lung crackles
- B. Bilateral lung crackles
- C. Self-reported pain of 2010
- D. Urine output of 20 ml/2 hr
Correct Answer: D
Rationale: Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to receiving ketorolac. A urine output of 20 ml/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and a pain report of 3 are not related.
A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
- A. Nursing/rite pain
- B. Behavioral assessment
- C. Objective observation
- D. Client self-report
Correct Answer: D
Rationale: Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
A nurse is preparing to give an infusion of acetaminophen (Ofirmev). The pharmacy delivers a bag containing 50 ml of normal saline and the Ofirmev. At what rate does the nurse set the IV pump to deliver this dose? (Record your answer using a whole number.) ml/hr
- A. 100 ml/hr
- B. 150 ml/hr
- C. 200 ml/hr
- D. 250 ml/hr
Correct Answer: C
Rationale: Intravenous acetaminophen (Ofirmev) is given by a 15-minute infusion. To deliver 50 ml in 15 minutes, set the IV pump for 200 ml/hr (50 ml ÷ 0.25 hr = 200 ml/hr).
A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client is to the client. The nurse issues the client is to the possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
- A. Being able to sleep dosent means pain doesit exist.
- B. Have you ever experienced any type of pain?
- C. The client should be assessed for drugg addiction.
- D. Your right right I would pain the medication back.
Correct Answer: A
Rationale: A clients description is the most accurate assessment of pain. The nurse should believe the client and provide pain cited. Physiologic changes due to pain vary from the client to client, and assessments of pain should not supervised the clients descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippain, and does not provide useful information. This amount of information does not be the client is to the client.