Nokea
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.
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A postoperative client has a nursing diagnosis of Ineffective Breathing Pattern and is fearful that movement may result in more pain. Which of the following would be most appropriate for the nurse to do?
- A. Get the client out of bed.
- B. Have the client do deep breathing.
- C. Encourage the client to lie still in bed.
- D. Get the client to cough every 2 hours.
- E. Administer more pain medication.
Correct Answer: A,B,D
Rationale: The client taking an opioid may be fearful that exercise will cause more pain. To help overcome this fear, the nurse should get the client out of bed and encourage therapeutic activities, such as deep breathing, coughing, and leg exercises, (when ordered). Having the client lie still in bed and giving more pain medication would be inappropriate.
A nurse would expect that epidural administration of opioid analgesics is reserved for which of the following?
- A. Labor pain
- B. Support of anesthesia
- C. Postoperative pain
- D. Moderate acute pain
- E. Intractable chronic pain
Correct Answer: A,C,E
Rationale: Epidural administration of opioid analgesics is reserved for postoperative pain, labor pain, and intractable chronic pain.
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.
A nurse should be aware of contraindications to the use of opioids to help decrease the likelihood of adverse reactions. The nurse understands that opioids would be contraindicated in which client?
- A. A client with acute bronchial asthma
- B. A client with an acute myocardial infarction
- C. A client with a head injury
- D. A client with grand mal seizures
- E. A client with mild renal impairment
Correct Answer: A,C,D
Rationale: The use of opioids is contraindicated in clients with acute bronchial asthma, emphysema, upper airway obstruction, head injury, increased intracranial pressure, convulsive disorders, severe renal or hepatic dysfunction, and acute ulcerative colitis.
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.