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A client is receiving an opioid analgesic following abdominal surgery. The client has been out of bed to the chair and is encouraged to ambulate with assistance. The nurse is also encouraging the client to increase his fluids. He reports that his appetite is good and he has been finishing most of his meals. His bowel sounds are active but he is having difficulty passing stools. A laxative is ordered. Which nursing diagnosis would be most appropriate?
- A. Imbalanced Nutrition: Less Than Body Requirements
- B. Constipation
- C. Risk for Injury
- D. Deficient Knowledge
Correct Answer: B
Rationale: The client is most likely experiencing constipation from the opioid therapy as well as from the lack of ambulation and activity. The client is eating, so imbalanced nutrition is not necessarily a problem.
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A nurse is assigned to care for a client who has been prescribed an opioid analgesic. Which of the following activities should the nurse perform as part of the preadministration assessment?
- A. Document description of pain and an estimate of when the pain began.
- B. Obtain client's blood pressure and pulse within 5 to 10 minutes.
- C. Monitor the client for symptoms of respiratory depression.
- D. Record each bowel movement and its appearance, color, and consistency.
Correct Answer: A
Rationale: The nurse should document the description of pain and an estimate of when the pain began as part of the preadministration assessment. Obtaining blood pressure and pulse within 5 to 10 minutes, monitoring the client for symptoms of respiratory depression, and recording bowel movements are part of the ongoing assessments conducted by the nurse when caring for the client.
A nurse would expect that epidural administration of opioid analgesics is reserved for which of the following?
- A. Labor pain
- B. Support of anesthesia
- C. Postoperative pain
- D. Moderate acute pain
- E. Intractable chronic pain
Correct Answer: A,C,E
Rationale: Epidural administration of opioid analgesics is reserved for postoperative pain, labor pain, and intractable chronic pain.
A client is prescribed an opioid analgesic. The initial interview reveals that the client chronically drinks alcohol. The nurse would assess the client for which of the following as a possible interaction between the opioid analgesic and alcohol?
- A. Respiratory depression
- B. Central nervous system depression
- C. Hypotension
- D. Sedation
Correct Answer: B
Rationale: The nurse should monitor the client for central nervous system depression. The nurse need not monitor the client for respiratory depression, hypotension, or sedation because these are the effects of the interaction of opioid analgesics with barbiturates, not alcohol.
A nurse has administered an opioid to a client. Which of the following would the nurse do if the client shows a decrease in respirations?
- A. Monitor and encourage the client to cough and breathe deeply every 2 hours.
- B. Instruct the client to restrict his consumption of liquids.
- C. Instruct the client to take complete bed rest.
- D. Instruct the client to avoid any kind of exercise.
Correct Answer: A
Rationale: The nurse should encourage the client to cough and breathe deeply every 2 hours if the client shows a decrease in respirations after the administration of opioid analgesics. The nurse need not instruct the client to restrict his consumption of liquids to help him cope with the effects of an ineffective breathing pattern.
A client is prescribed a transdermal opioid. After teaching the client and family how to administer this drug, the nurse determines that the teaching was successful when they state which of the following?
- A. The drug should be reapplied every 24 hours.
- B. We should try to apply the patch to about the same site each time.
- C. The site should only be cleaned with water before each application.
- D. A hairy area, like the forearm, is an appropriate place to apply the patch.
Correct Answer: C
Rationale: Only water is used to clean the site because soap and other substances may irritate the skin. The patch is applied for 72 hours and sites should be rotated. Any site that is used should be free of hair.