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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.
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A group of nursing students are reviewing information about epidural pain management with opioid analgesics. The students demonstrate understanding of the information when they identify which of the following as an advantage over other routes of administration?
- A. Longer time to tolerance development
- B. Lower total dose of opioid
- C. Fewer adverse reactions
- D. Greater client comfort
- E. Decreased demand on nursing staff
Correct Answer: B,C,D
Rationale: Epidural administration offers several advantages over other routes of administration for opioid analgesics, including lower total dosages of the drug used, fewer adverse reactions, and greater client comfort.
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 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.
Which of the following would alert the nurse to suspect that a client is experiencing intermediate manifestations of abstinence syndrome?
- A. Rhinorrhea
- B. Increased blood pressure
- C. Tachycardia
- D. Mydriasis
- E. Miosis
Correct Answer: C,D
Rationale: Intermediate symptoms of abstinence syndrome include mydriasis, tachycardia, twitching, tremor, restlessness, irritability, anxiety, and anorexia.
A nurse is caring for a newborn. The newborn's mother is suspected to be opioid dependent. When assessing the newborn, which of the following would alert nurse to the possibility of withdrawal?
- A. Jaundice
- B. Increased respiratory rate
- C. Decreased respiratory rate
- D. Sneezing
- E. Fever
Correct Answer: B,D,E
Rationale: Opiate withdrawal symptoms in a newborn usually appear during the first few days of life and include irritability, excessive crying, yawning, sneezing, increased respiratory rate, tremors, fever, vomiting, and diarrhea.