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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.
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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.
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 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.
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 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.