Nokea
A nurse is caring for a client who is receiving naloxone intravenously. The client develops acute pain while the drug is being administered. Which of the following would most likely explain the client's pain level?
- A. The drug was administered as too rapid a dose.
- B. The client's pain wasn't controlled before the administration of naloxone.
- C. The change in respiratory status has caused the increase in pain.
- D. The dosage of the naloxone was too small.
Correct Answer: A
Rationale: When naloxone is given IV and the bolus is given too rapidly, withdrawal symptoms and the return of intense pain occur as the level of opioid is reduced. There is no indication that the client's pain hadn't been controlled previously. A change in the respiratory status does not lead to increased pain. If the dose was too small, the client would still be experiencing some of the effects of the opioid that is being reversed.
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An opioid-naïve client experiences acute pain after surgery and is prescribed opioid therapy. The nurse would be especially alert for the development of which of the following?
- A. Pruritus
- B. Severe headache
- C. Respiratory depression
- D. Urticaria
Correct Answer: C
Rationale: The nurse should monitor for symptoms of respiratory depression developing in the client as one of the severe adverse reactions of opioid treatment. Pruritus, urticaria, and headache are caused by opioids, but these conditions are not the most severe and common adverse reactions observed in opioid-naïve clients.
A client is prescribed naloxone for the treatment of postoperative acute respiratory depression after a kidney transplant. The nurse explains the drug to the family, describing its action as which of the following?
- A. Naloxone stops internal bleeding.
- B. Naloxone restores respiratory function.
- C. Naloxone restores reflexes of limbs.
- D. Naloxone helps the client overcome pain.
Correct Answer: B
Rationale: The nurse should explain that naloxone restores respiratory function within 1 to 2 minutes after administration. Naloxone neither stops internal bleeding nor restores limb reflexes. Naloxone also does not overcome pain.
Abrupt reversal of opioid-induced respiratory depression may cause vomiting. Which action by the nurse would be most appropriate if this occurs during reversal of opioid-induced respiratory depression?
- A. Maintaining a patent airway
- B. Stopping the opioid antagonist
- C. Suctioning the client as needed
- D. Administering more of the opioid
- E. Turning the client to the side as needed
Correct Answer: A,C,E
Rationale: If vomiting occurs during the reversal of opioid-induced respiratory depression, the nurse must maintain a patent airway and should turn and suction the client as needed.
A client is admitted to a local health care facility for alcohol dependence. The nurse knows that the physician is most likely to prescribe which of the following drugs for the client?
- A. Cisapride
- B. Naproxen
- C. Lincosamide
- D. Naltrexone
Correct Answer: D
Rationale: The nurse should administer naltrexone to the client who has alcohol dependence. It is also used to block the effects of suspected opioids if they are being used by the person undergoing treatment for alcohol dependence. Cisapride, naproxen, and lincosamide are not used to treat alcohol dependence.
A client with chronic back pain is admitted to a local health care facility for respiratory depression secondary to an inadvertent overdose of his opioid analgesic. The client is to receive naloxone. Which of the following would the nurse include before administering naloxone?
- A. Monitor the client's blood pressure every 5 minutes.
- B. Review the client's allergy history and treatment modalities.
- C. Monitor vital signs every 5 to 15 minutes if the client is responsive.
- D. Monitor respiratory rate and rhythm of the client.
Correct Answer: B
Rationale: Before administering the antagonist, the nurse should review the client's initial health history, allergy history, and treatment modalities. The nurse should also obtain the client's blood pressure, pulse, and respiratory rate and review the record for the drug suspected of causing the symptoms of respiratory depression. All these interventions are part of the preadministration assessment.