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A client with respiratory depression is administered an opioid antagonist by the nurse. What ongoing assessment should the nurse perform when administering the opioid antagonist to the client?
- A. Monitor vital signs every 5 to 15 minutes.
- B. Review allergy history and other treatment modalities.
- C. Teach different breathing patterns to the client.
- D. Monitor the blood pH level of the client.
Correct Answer: A
Rationale: The ongoing assessment performed by the nurse when administering an opioid antagonist to the client involves monitoring the vital signs of the client every 5 to 15 minutes. Monitoring the blood pH level of the client is not part of the ongoing assessment. Reviewing the allergy history and other treatment modalities and teaching different breathing patterns to the client are preadministration assessments that are performed before the administration of the drug; they are not ongoing assessments.
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A nurse suspects that a client receiving naloxone is experiencing an adverse reaction when the assessment reveals which of the following?
- A. Bradycardia
- B. Dry, flushed skin
- C. Tremors
- D. Diarrhea
Correct Answer: C
Rationale: Generalized reactions to naloxone include nausea and vomiting, sweating, tachycardia, increased blood pressure, and tremors.
Prior to the administration of an opioid antagonist, which of the following would be most important for the nurse to obtain?
- A. Blood pressure
- B. Blood glucose
- C. Pulse
- D. Pain assessment
- E. Respiratory rate
Correct Answer: A,C,E
Rationale: Prior to the administration of an opioid antagonist, the nurse must obtain the client's blood pressure, pulse, and respiratory rate.
Which of the following are evaluations the nurse should make when caring for a client receiving naloxone?
- A. Pain relief is resumed.
- B. Adverse reactions are identified and managed.
- C. Therapeutic response is achieved.
- D. Client demonstrates an understanding of the drug regimen.
- E. Client's respiratory rate is normal.
Correct Answer: A,B,C,D,E
Rationale: Pain relief is resumed, adverse reactions are identified and managed, therapeutic response is achieved, client demonstrates an understanding of the drug regimen, and client's respiratory rate is normal are evaluations of successful therapy with an opioid antagonist.
When administering an opioid antagonist to reverse opioid-induced respiratory depression, which of the following would be most important for the nurse to keep in mind?
- A. Monitoring is less frequent if respiratory depression occurs in the immediate postoperative setting.
- B. The nurse should notify the primary health care provider if any adverse drug reactions occur.
- C. After the client has shown a response to the drug, the nurse monitors vital signs every 30 to 60 minutes.
- D. Monitoring of the client's respiratory status includes rate, rhythm, and depth.
- E. The nurse monitors the client's blood pressure, pulse, and respiratory rate at frequent intervals, usually every 3 minutes, until the client responds.
Correct Answer: B,D
Rationale: As part of the ongoing assessment during the administration of the antagonist, continue to monitor the blood pressure, pulse, and respiratory rate at frequent intervals, usually every 5 minutes, until the client responds. This monitoring should be more frequent if respiratory depression occurs in the immediate postoperative setting. After the client has shown a response to the drug, monitor vital signs every 5 to 15 minutes. Notify the anesthesiologist or primary health care provider if any adverse drug reactions occur because additional medical treatment may be needed. Continue to monitor the respiratory rate, rhythm, and depth; pulse; blood pressure; and level of consciousness until the effects of the opioid wear off.
A nursing student is assigned to lead a class discussion on opioid antagonists. Which of the following would the student include as the mechanism by which opioid antagonists reverse the effects of opioid agonists?
- A. Competitive inhibition of the opioid receptor
- B. Direct binding to the opioid agonist
- C. Displacement of the opioid agonist from the opioid receptor
- D. Irreversible inhibition of the opioid receptor
- E. Mutation of the opioid receptor
Correct Answer: A,C
Rationale: Opioid agonists reverse the opioid effects by competing for the opiate receptor site and displacing the opioid drug.