Nokea
When administering an opioid antagonist to reverse opioid-induced respiratory depression, which of the following would be most important for the nurse to keep in mind?
- A. Monitoring is less frequent if respiratory depression occurs in the immediate postoperative setting.
- B. The nurse should notify the primary health care provider if any adverse drug reactions occur.
- C. After the client has shown a response to the drug, the nurse monitors vital signs every 30 to 60 minutes.
- D. Monitoring of the client's respiratory status includes rate, rhythm, and depth.
- E. The nurse monitors the client's blood pressure, pulse, and respiratory rate at frequent intervals, usually every 3 minutes, until the client responds.
Correct Answer: B,D
Rationale: As part of the ongoing assessment during the administration of the antagonist, continue to monitor the blood pressure, pulse, and respiratory rate at frequent intervals, usually every 5 minutes, until the client responds. This monitoring should be more frequent if respiratory depression occurs in the immediate postoperative setting. After the client has shown a response to the drug, monitor vital signs every 5 to 15 minutes. Notify the anesthesiologist or primary health care provider if any adverse drug reactions occur because additional medical treatment may be needed. Continue to monitor the respiratory rate, rhythm, and depth; pulse; blood pressure; and level of consciousness until the effects of the opioid wear off.
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A nurse monitoring a client receiving naloxone (Narcan) should be cognizant for the development of which of the following adverse reactions?
- A. Nausea
- B. Constipation
- C. Tachycardia
- D. Hypotension
- E. Tremors
Correct Answer: A,C,E
Rationale: Generalized reactions that can occur with the use of opioid antagonists such as naloxone include nausea, vomiting, sweating, tachycardia, increased blood pressure, and tremors.
After teaching a group of nursing students about opioid antagonists, the instructor determines that the teaching was successful when the students identify which of the following as true about these drugs?
- A. An opioid antagonist has greater affinity for opioid receptors than do opioid agonists.
- B. An opioid antagonist has lesser affinity for opioid receptors than do opioid agonists.
- C. An opioid antagonist prevents a response to the opioid by binding to opioid agonists in the bloodstream.
- D. An opioid antagonist prevents a response to the opioid by binding to opioid receptors.
- E. An opioid antagonist potentiates the effect of an opioid.
Correct Answer: A,D
Rationale: An opioid antagonist has a greater affinity for a cell receptor than an opioid agonist, and by binding to the cell receptor, it prevents a response to the opioid agonist.
Which of the following are evaluations the nurse should make when caring for a client receiving naloxone?
- A. Pain relief is resumed.
- B. Adverse reactions are identified and managed.
- C. Therapeutic response is achieved.
- D. Client demonstrates an understanding of the drug regimen.
- E. Client's respiratory rate is normal.
Correct Answer: A,B,C,D,E
Rationale: Pain relief is resumed, adverse reactions are identified and managed, therapeutic response is achieved, client demonstrates an understanding of the drug regimen, and client's respiratory rate is normal are evaluations of successful therapy with an opioid antagonist.
Which of the following would a nurse most likely be ordered to give to a client experiencing opioid-induced respiratory depression?
- A. Naloxone
- B. Nalbuphine
- C. Naltrexone
- D. Naproxen
- E. Nitroglycerin
Correct Answer: A
Rationale: Naloxone is an opioid antagonist specifically developed to reverse respiratory depression associated with opioids. Naltrexone may also be used, but its primary use is in the treatment of alcohol dependence. Nalbuphine is an agonist-antagonist used for severe chronic pain. Naproxen is an NSAID. Nitroglycerin is used for angina.
A client is prescribed naloxone. The nurse would expect to administer the drug by which route?
- A. IM injection
- B. IV push
- C. Intrathecal injection
- D. IV piggyback
- E. Subcutaneous injection
Correct Answer: B,D
Rationale: Naloxone (Narcan) is administered by IV infusion requiring the use of a secondary line, an IV piggyback, or an IV push.