Nokea
A nurse is caring for a client with chronic pain who has been prescribed epidural analgesia. The nurse monitors the client for which of the following after insertion of the epidural catheter and throughout the therapy?
- A. Abdominal pain
- B. Respiratory depression
- C. Fever
- D. Nervousness
Correct Answer: B
Rationale: The most serious adverse reaction associated with the epidurally administered opioids is respiratory depression. The nurse should closely monitor the client for respiratory depression after insertion of the epidural catheter and throughout the therapy.
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A nurse is to administer a prescribed opioid to a client. Which of the following conditions should the nurse confirm in the client to ensure that opioid therapy is not contraindicated in this client?
- A. Client does not have acute bronchial asthma.
- B. Client does not have acute diabetic retinopathy.
- C. Client does not have acute pre-existing liver disease.
- D. Client does not have decreased intracranial pressure.
Correct Answer: A
Rationale: Opioid therapy is contraindicated in clients with acute bronchial asthma; therefore, the nurse should confirm that the client does not have this condition before administering opioid therapy. Opioid therapy is not known to be contraindicated in clients with diabetic retinopathy and pre-existing liver disease. Opioid therapy is contraindicated in clients with increased, not decreased, intracranial pressure.
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.
After teaching a group of nursing students about opioids, the instructor determines that additional teaching is needed when the students identify which of the following as a natural opioid?
- A. Meperidine
- B. Morphine
- C. Codeine
- D. Opium
Correct Answer: A
Rationale: Meperidine is a synthetic opioid. Natural opioids include morphine sulfate, codeine, opium alkaloids, and tincture of opium.
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.
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.