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A nurse is assessing a client who is to receive an opioid analgesic. The nurse would contact the primary health care provider immediately if which of the following occur?
- A. Respiratory rate of less than 10 breaths/min
- B. Decrease in pulse
- C. Increase in pulse
- D. Increase in blood pressure
- E. Blood pressure of 90/65 mm Hg
Correct Answer: A,B,C,E
Rationale: The nurse should contact the primary health care provider immediately if any of the following occur while a client is receiving an opioid analgesic: significant decrease in respiratory rate or a respiratory rate less than 10 breaths/min; significant increase or decrease in the pulse rate or a change in the pulse quality; or significant decrease in blood pressure or a systolic blood pressure below 100 mm Hg.
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A nurse is caring for a client who has been prescribed an opioid. Which of the following would the nurse include in the ongoing assessment?
- A. Review the client's health history.
- B. Review the client's allergy history.
- C. Inquire about the pain experienced by the client.
- D. Review the client's past and current drug therapies.
Correct Answer: C
Rationale: As part of the ongoing assessment, the nurse should inquire about the pain experienced by the client and believe the client and family in their reports of pain. The nurse must exercise good judgment because not all changes in pain type, location, or intensity require notifying the primary health care provider.
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.
To decrease the risk of injury to a client taking an opioid, which action would be most appropriate?
- A. Keep the lights in the client's room turned down.
- B. Assist the client from the bed to the toilet.
- C. Assist the client with rising Ang from a lying position.
- D. Assist the client with hall-walking activities.
- E. Advise the client to stay in bed all night.
Correct Answer: B,C,D
Rationale: To decrease the risk of injury to a client taking an opioid, the nurse should assist the client with ambulatory activities and with rising from a sitting or lying position. The nurse should also keep the client's room well lit during daytime hours, keep the client's room free of clutter, and advise the client to seek assistance when getting out of bed at night.
A nurse assesses a client for common adverse reactions of opioids. Which of the following would the nurse identify?
- A. Respiratory depression
- B. Diarrhea
- C. Mydriasis
- D. Constipation
- E. Miosis
Correct Answer: A,D,E
Rationale: Respiratory depression, miosis, and constipation are examples of common adverse reactions seen with the use of opioids.
A nurse is caring for a client with pain caused by terminal illness. The primary care provider has prescribed an opioid for the client. The nurse would be alert for the development of which of the following?
- A. Emphysema
- B. Alopecia
- C. Dehydration
- D. Severe anorexia
Correct Answer: D
Rationale: The nurse should monitor the client for severe anorexia, which is one of the adverse reactions of opioid analgesics on the GI system. Other adverse effects on the GI system include constipation, nausea, and acute abdominal pain. The nurse need not monitor the client for emphysema, alopecia, or severe headache.