Chapter 10 Analgesic Drugs

A patient is prescribed sufentanil for the treatment of acute pain. The nurse instructs the patient to increase fluid intake up to 3000 mL per day to prevent which side effect of sufentanil? 1 Crystalluria 2 Constipation 3 Mucosal irritation 4 Electrolyte imbalance

2 Constipation --- Sufentanil is an opioid drug. Administration of opioid drugs reduces peristalsis because of central nervous system depression and may result in constipation. Therefore the nurse instructs the patient to increase fluid intake up to 3000 mL per day to prevent constipation. Sufentanil does not cause crystalluria, mucosal irritation, or electrolyte imbalance.

A patient who regularly takes acetaminophen returns to the clinic for a follow-up visit. Which assessment finding indicates the need for a change in the patient's therapy? 1 Hemoglobin 11.2 g/dL 2 Serum bilirubin 3.2 mg/dL 3 Serum creatinine 0.8 mg/dL 4 Random blood glucose 140 mg/dL

2 Serum bilirubin 3.2 mg/dL --- Acetaminophen used for pain relief can be hepatotoxic if taken in large doses. Elevated serum bilirubin indicates chemical damage to the liver. A serum bilirubin level of 3.2 mg/dL is much higher than normal; it indicates hepatotoxicity and the need for a change in therapy. A hemoglobin level of 11.2 g/dL, serum creatinine level of 0.8 mg/dL, and random blood glucose level of 140 mg/dL are within the normal range.

Before the scheduled dose of opioids, the nurse assesses the patient's vital signs. The respiratory rate is 8 breaths/min, pulse rate is 80 beats/min, and blood pressure is 108/60 mm Hg. Which action would the nurse take first? 1 Administer an opioid antagonist. 2 Withhold the scheduled opioid dose. 3 Administer the scheduled opioid dose. 4 Inform the primary health care provider.

2 Withhold the scheduled opioid dose. --- Opioids may cause respiratory depression, and the nurse would be vigilant. This patient has a respiratory rate of 8 breaths/min, which is an abnormal finding; therefore the patient's dose of opioids would be withheld. The nurse holds the opioid dose and reassesses. If the rate remains low, the patient would receive an opioid antagonist. The primary health care provider would also be notified.

Which response would the nurse give to explain why codeine has been prescribed for a patient admitted to the hospital with a chronic nonproductive dry cough? 1 "This medication helps to open up your airways." 2 "This medication will help your immune system." 3 "This medication is used as a cough suppressant." 4 "This medication will help you get rid of mucous."

3 "This medication is used as a cough suppressant." --- Codeine provides both analgesic and antitussive (cough suppressant) therapeutic effects. Codeine does not help the immune system. It is inaccurate to say that codeine gets rid of mucous or opens up the airways.

A patient is prescribed high-dose acetaminophen for long-term treatment of pain. Which medication may be part of the patient's treatment plan to prevent complications associated with acetaminophen toxicity? 1 Naloxone 2 Nalbuphine 3 Acetylcysteine 4 Naltrexone hydrochloride

3 Acetylcysteine --- Acetaminophen is a nonopioid drug. Higher doses of acetaminophen may increase the risk for acute hepatotoxicity and liver damage. Liver damage from acetaminophen may be minimized by timely dosage of acetylcysteine. Therefore acetylcysteine would be involved in the patient's treatment plan to prevent complications associated with acetaminophen. Naloxone is an opioid antagonist used for the treatment of opioid toxicity. Nalbuphine is an opioid agonist-antagonist. Naltrexone hydrochloride is an opioid antagonist used in the treatment of opioid toxicity.

The nurse assesses a respiratory rate of 6 breaths/min in a patient receiving fentanyl. Which action would the nurse take? 1 Assess the patient for pain. 2 Administer an amphetamine. 3 Administer naltrexone hydrochloride. 4 Assess the patient's electrocardiogram (ECG)

3 Administer naltrexone hydrochloride. --- The patient may have respiratory depression from the fentanyl, an opioid drug that may depress the respiratory center. Therefore naltrexone hydrochloride would be administered to the patient to reverse the action of fentanyl and to improve the patient's respiratory status. When in pain, a patient's respiratory rate typically increases, rather than decreases. Administering an amphetamine will not reverse the effects of the fentanyl. There is no immediate need to assess the ECG.

Gallstones produce which type of pain? 1 Deep pain 2 Somatic pain 3 Visceral pain 4 Superficial pain

3 Visceral pain --- Visceral pain originates from organs and smooth muscles. The gallbladder is an organ, so the pain that the patient is experiencing is known as visceral pain. Deep pain occurs in tissues below skin level. Somatic pain originates from the skeletal muscles, ligaments, and joints. Superficial pain originates from the skin and mucous membranes.

Somatic pain originates from which location in the body? 1 Organs and smooth muscles 2 Skin and mucous membranes 3 Vascular or perivascular tissues 4 Skeletal muscles, ligaments, and joints

4 Skeletal muscles, ligaments, and joints --- Somatic pain is a pain that originates from skeletal muscles, ligaments, and joints. Somatic pain does not originate from organs, skin and mucous membranes, or blood vessels. Pain that originates from organs and smooth muscles is called visceral pain. Pain that originates from skin and mucous membranes is called superficial pain. Pain that originates from vascular or perivascular tissues is called vascular pain.

The nurse administered oral codeine sulfate to a patient as needed (PRN) for suppression of a nonproductive dry cough. When would the nurse assess to determine whether the medication has been effective? 1 In 8 hours 2 In 4 hours 3 Within 2 hours 4 Within a half hour

4 Within a half hour --- Codeine sulfate is derived from codeine, which is a natural opiate alkaloid obtained from opium. The nurse would assess within a half hour to determine whether the medication has worked because the onset of action is 15 to 30 minutes. The duration of action of codeine sulfate is 4 to 6 hours. If the medication is ordered PRN, there will be a time frame on the medication as to when the next dose can be administered that corresponds to the duration of action of the drug (4 to 6 hours). The nurse would assess in 4 hours to determine whether the patient needs another dose.

The nurse is caring for a patient who is receiving 15 mg of morphine through an intravenous (IV) line over 12 hours. It needs to be changed to IV hydromorphone. Calculate the equivalent IV hydromorphone dose for 24 hours. Record your answer using one decimal place. _____ mg

4.5mg --- The 24-hour dose of morphine is 30 mg (15 mg × 2). Equianalgesic dose of morphine and hydromorphone: 10 mg of parenteral morphine = 1.5 mg of parenteral hydromorphone.24-hour amount of morphine (30 mg) = Equianalgesic dose of current drug (10 mg)Amount of desired opioid for 24 hours (x) Equianalgesic dose of desired drug (1.5 mg)(30 mg × 1.5 mg) = 10x mg45 mg/10 mg = xx = 4.5 mgAmount of desired opioid hydromorphone in 24 hours (x) = 4.5 mg.

Which assessment is essential for the nurse to monitor in a patient who is receiving an opioid analgesic? 1 Heart rate 2 Mental status 3 Blood pressure 4 Respiratory rate

4 Respiratory rate --- The most serious side effect of opioid analgesics is respiratory depression. When death occurs from opioid overdose, it is almost always from respiratory depression. Opioids can also cause bradycardia, disorientation, and hypotension, but respiratory depression is the most important adverse effect for which the nurse would assess.

How would the nurse respond when a patient asks how to use a fentanyl patch at home? 1 "Keep new and used patches away from children." 2 "Apply heat over the patch to increase absorption." 3 "Dispose of patches by melting them with a flame." 4 "Store the patches in the bathroom medicine cabinet."

1 "Keep new and used patches away from children." --- New and used patches must be kept away from children and pets for their safety. Heat should never be applied over the patch because it will increase absorption and could lead to overdosing. Dispose of patches by folding in half and flushing down the toilet. Storing the patches in the bathroom medicine cabinet exposes them to moisture which can degrade the medication.

The nurse cares for a patient on the second day after major abdominal surgery. The patient is receiving morphine via patient-controlled analgesia (PCA) and currently reports pain as a 2 on a scale of 0 to 10. The patient tearfully says to the nurse, "I'm so worried that I won't be able to go back to work. How am I going to manage my bills?" Which statement is the best response by the nurse? 1 "Tell me more about your fears." 2 "Your pain is well controlled now. Why are you so worried?" 3 "Everything will be fine. You will be back to work in about 6 weeks." 4 "The disability benefit of your insurance plan will help pay your bills."

1 "Tell me more about your fears." --- Anxiety exacerbates the pain experience. By demonstrating caring and concern and using therapeutic communication skills such as active listening and open-ended questions, the patient's anxiety can be explored. Telling the patient that the insurance plan will help to pay bills will not completely alleviate the patient's anxiety. Telling the patient that the pain is under control and not to worry shows a lack of concern for the patient's feelings. Telling the patient that it will take only 6 weeks to get well may be a false reassurance because it may take longer for the patient to recover.

Which medication will assist a patient who is experiencing constipation as a side effect of opioid therapy? 1 Lactulose 2 Naloxone 3 Promethazine 4 Diphenhydramine

1 Lactulose --- Constipation is a common side effect of opioid therapy. Agents such as lactulose have been proven to be effective in the treatment of constipation. Naloxone is an opioid antagonist used to improve respiratory status. Promethazine is an antiemetic used if the patient is experiencing nausea and vomiting. Diphenhydramine is used in the treatment of pruritus, which is an adverse effect of opioid therapy.

A patient is diagnosed with fibromyalgia. Which drug does the nurse expect to administer? 1 Milnacipran 2 Tramadol hydrochloride 3 Naloxone hydrochloride 4 Naltrexone hydrochloride

1 Milnacipran --- Fibromyalgia is a condition in which the level of norepinephrine is reduced in the brain. Milnacipran is used for the treatment of fibromyalgia. Milnacipran is a selective serotonin and norepinephrine reuptake inhibitor. Milnacipran increases norepinephrine levels and reduces pain associated with the fibromyalgia. Tramadol hydrochloride is indicated for the treatment of moderate to moderately severe pain. Naloxone hydrochloride and naltrexone hydrochloride are opioid antagonists.

A postoperative patient is receiving an epidural infusion of morphine sulfate. The patient's respiratory rate decreases to 8 breaths/min. Which medication would the nurse administer after attempting to have the patient respond to verbal and tactile stimuli? 1 Naloxone 2 Acetylcysteine 3 Protamine sulfate 4 Methylprednisolone

1 Naloxone --- A respiratory rate of 8 breaths/min indicates respiratory depression. Naloxone is a narcotic antagonist that will reverse this effect of morphine sulfate. Acetylcysteine is used for acetaminophen toxicity. Protamine sulfate is used to reverse the drug effects of heparin. Methylprednisolone is administered to alleviate cytokine release syndrome caused by basiliximab and daclizumab, which are used to prevent rejection of transplanted kidneys.

Which outcomes are adverse effects of Chrysanthemum parthenium? Select all that apply. 1 Nausea 2 Joint pain 3 Skin rashes 4 Blurred vision 5 Muscle stiffness

1 Nausea 2 Joint pain 5 Muscle stiffness --- Chrysanthemum parthenium is also known as feverfew. It is commonly used for the treatment of migraine headaches, menstrual cramps, inflammation, and fever. Nausea, joint pain, and muscle stiffness are the adverse effects of Chrysanthemum parthenium. Chrysanthemum parthenium does not produce any effect on skin integrity or vision.

A patient has taken an excessive dose of acetaminophen for pain management. Which adverse effects associated with acetaminophen are likely to be found in the patient? Select all that apply. 1 Nausea 2 Vomiting 3 Blurred vision 4 Decreased hearing 5 Elevated liver enzymes

1 Nausea 2 Vomiting 5 Elevated liver enzymes --- Nausea, vomiting, and elevated liver enzymes are the effects of an excess dose of acetaminophen. Acetaminophen does not affect vision or hearing function.

The nurse is assessing patients who are in severe pain. Which patient can safely receive morphine for pain relief? 1 Patient A - Spinal tumor with lung metastasis; blood pressure 120/80 mmHg 2 Patient B - Complete femur fracture with serum creatinine level 1.8 mg/dl 3 Patient C - Metastatic cancer; respiratory rate 10 breaths/min 4 Patient D - Multiple injuries sustained through major vehicle crash; under the influence of alcohol

1 Patient A --- Patient A has spinal cancer with metastasis and is in severe pain. Morphine is used to treat moderate to severe pain. The patient has stable vital signs and can receive morphine for pain relief. Patient B has renal impairment, as evidenced by a high serum creatinine value, which might lead to the accumulation of the drug metabolite. The metabolite of morphine is toxic. If the metabolite is not excreted and instead accumulates, it might lead to toxicity or other complications. Patient C has bradypnea. Morphine, when given in high doses, causes respiratory depression, so Patient C would not receive morphine. Patient D is under the influence of alcohol, and coadministration of morphine with alcohol can result in respiratory depression.

After the placement of a new transdermal opioid patch, the patient complains of an increase in level of pain. Which error in placement of the new patch is the reason? 1 Placed on a hairy area 2 Placed on an area after cleaning it 3 Placed on the same place as the old patch 4 Placed on a new area, with the old patch still in place

1 Placed on a hairy area --- Transdermal patches are an effective and easy method of pain relief. However, the presence of hair on the application area may interfere with absorption of the medication, resulting in ineffective pain relief. Therefore, the patch would be applied in a nonhairy area. For maximum therapeutic effect, the new patch would be applied after cleaning the area. The new patch may cause skin irritation if placed on the same place as the old patch, but it would not affect the drug's effectiveness. If the old and new patches both remain on the patient's body, it may lead to overdose.

A patient is being discharged with a prescription for morphine for postoperative pain. Which information would the nurse include in the discharge teaching plan? Select all that apply. 1 "Rest before taking the medication." 2 "Drink at least 3 liters of fluid a day." 3 "Take acetaminophen with the morphine." 4 "Take an over-the-counter stool softener daily." 5 "Increase the dose of morphine if there is no relief of pain."

2 "Drink at least 3 liters of fluid a day." 4 "Take an over-the-counter stool softener daily." --- Constipation is one of the major side effects of morphine administration. It may be managed with increased intake of fluids and the use of over-the-counter stool softeners. Adequate rest is required for a patient who has undergone surgery. It is, however, not important before taking the morphine. Acetaminophen does not have to be taken with the morphine. The details of medication dosage are provided in the discharge summary. The medication would never be increased without discussion with the primary health care provider.

The nurse teaches a patient prescribed the fentanyl transdermal delivery system to change the patch at which interval? 1 Once a week 2 Every 72 hours 3 Every 24 hours 4 When pain recurs

2 Every 72 hours --- The fentanyl transdermal delivery system is designed to slowly release analgesic over a 72-hour time frame. The patient would not change the patch when pain recurs, once a week, or every 24 hours.

Which factor would the nurse consider while planning pharmacologic therapy for a patient with pain? 1 Narcotic analgesics should not be used for more than 24 hours. 2 Pain relief is best obtained by administering analgesics around the clock. 3 Analgesics should be administered as needed to minimize adverse effects. 4 Patients should request analgesics when the pain level reaches a 3 on a scale of 1 to 10.

2 Pain relief is best obtained by administering analgesics around the clock. --- Studies have demonstrated that analgesics administered around the clock rather than on an as-needed basis provide the optimal pain relief. Narcotic analgesics have a potential for addiction, but pain management is more important, so they may be used for more than 24 hours. A rating of 3 on the pain scale may indicate effective pain relief.

Which assessment finding indicates that the patient may have received an overdose of morphine sulfate? 1 Blood in urine 2 Pinpoint pupils 3 Heart rate 110 beats/min 4 Respiratory rate 28 breaths/min

2 Pinpoint pupils --- Morphine sulfate is an opioid drug used for pain management. After administration of morphine sulfate, the nurse would assess the patient's pupillary reaction to light. Pinpoint pupils indicate an overdose of morphine sulfate. Overdose of morphine sulfate does not cause blood in the urine, increased heart rate, or increased respiratory rate.

The nurse cares for a postoperative patient receiving epidural analgesia. The patient is resistant to the nurse's encouragement to turn, cough, and breathe deeply. The patient says, "I'm afraid the needle will stick in my spinal cord and paralyze me." How would the nurse respond? 1 "I can understand your fears, but there is no risk of paralysis from epidural analgesia." 2 "Tell me more about your understanding of how epidural analgesia relieves your pain." 3 "There's no needle. It's a thin plastic tube in the protective covering of your spinal cord." 4 "If you don't turn, cough, and breathe deeply, you may get pneumonia or other complications."

3 "There's no needle. It's a thin plastic tube in the protective covering of your spinal cord." --- The patient is communicating fear and has a misunderstanding of the epidural line. By educating the patient regarding the lack of an indwelling needle in epidural analgesia, the feelings of fear and worry will decrease, and the patient will be more willing to participate in the plan of care. Telling the patient that there is no risk of paralysis will not help alleviate the patient's fears, because it may not convince the patient. The nurse needs to quickly inform the patient about the equipment instead of discussing the inaccurate information that the patient has. Telling the patient about potential complications will increase the patient's anxiety.

A patient admitted to the unit is prescribed oral naltrexone hydrochloride daily. Which admission assessment would the nurse include for the patient? 1 Assessment of culture reports 2 Assessment of chronic diseases causing pain 3 Questions regarding the date of the last flu vaccine 4 Questions regarding past history of drug and alcohol use

4 Questions regarding past history of drug and alcohol use --- Naltrexone hydrochloride is used as an adjunct to psychosocial treatments for alcoholism. Naltrexone hydrochloride is an opioid antagonist. It is also used as an adjunct for the maintenance of an opioid-free state in former opioid addicts. The nurse would include questions regarding the patient's past history of drug and alcohol use and determine how long the patient has been on the medication. The medication is not prescribed as a treatment for infection or chronic pain. There is no need to ask the date of the last flu vaccine; it is not relevant.

Which action of naloxone binding on the opioid receptor causes reversal of respiratory depression? 1 Binds instead of the agonist and causes analgesia 2 Binds and causes less pain response than an agonist 3 Binds in place of the agonist and causes no response 4 Binds and causes a response opposite to that of an agonist

3 Binds in place of the agonist and causes no response --- Naloxone is a competitive antagonist because it competes with the opioid agonist to bind with the receptor but produces no response. It reduces the response of the agonist by displacing the agonist from the receptor site. In this way, it reverses the respiratory depression caused by the opioid agonist. If a drug binds to the receptor sites and produces a response, it means that the drug is an agonist that has more affinity to the receptor site than the original drug and causes analgesia. If a drug causes less response than that produced by an agonist even at full dose, it is called agonist-antagonist or a partial agonist. If a drug binds to the receptors and causes a response opposite to that of an agonist, then it is called an inverse agonist.

A patient's medication administration record has the following entry: morphine sulfate 1 mg IV push q2h PRN severe pain. Upon assessment, the patient continues to complain of pain that is 8 on a scale of 0 to 10. The patient received 1 mg of morphine an hour ago. Which action would the nurse take? 1 Administer 1 mg of morphine and notify the primary health care provider. 2 Hold the drug, record the assessment, and reassess the patient in 1 hour. 3 Consult the primary health care provider and obtain another drug prescription. 4 Administer another 1 mg of morphine and reevaluate the pain scale in 15 minutes.

3 Consult the primary health care provider and obtain another drug prescription. --- The nurse needs to consult with the primary health care provider on a medication for breakthrough pain. The patient is in severe pain. Hence the patient needs to be administered another analgesic for breakthrough pain, not 1 mg morphine sulphate q1h as this could cause opioid overdose. The nurse would not wait to treat the patient's pain.

Potencies of analgesics are determined using an equianalgesic table comparing doses of these drugs with which prototype? 1 Codeine 2 Fentanyl 3 Morphine 4 Meperidine

3 Morphine --- Equianalgesia refers to the ability to provide equivalent pain relief by calculating dosages of different drugs and/or routes of administration that provide comparable analgesia. If the opioid used is not morphine, the nurse will convert its dose to the equianalgesic dose of morphine.

A patient with cancer who has had adequate pain control with a long-acting opioid reports severe pain. The nurse understands that the patient is experiencing breakthrough pain, and the time of the next scheduled opioid dose is in 2 hours. Which action does the nurse take? 1 Administer the scheduled opioid dose early. 2 Ask the patient to bear the pain until the next scheduled opioid dose. 3 Distract the patient for 2 hours by using alternative methods, such as music therapy. 4 Administer a short-acting opioid and follow the regular opioid schedule for the next dose.

4 Administer a short-acting opioid and follow the regular opioid schedule for the next dose. --- Breakthrough pain occurs between two doses of opioids, usually as the effect of the opioid starts wearing off. A short-acting opioid can be administered for pain relief, maintaining the same schedule for the regular opioid. The nurse would not administer the regular long-acting opioid for breakthrough pain because it can cause an overdose. Music therapy may not be an effective method of pain relief. The nurse would not to ask the patient to bear the pain until the next scheduled opioid dose.

The nurse assesses a patient who is receiving methadone hydrochloride and notes a respiratory rate of 10 breaths/min. Which action by the nurse is a priority? 1 Assess blood gasses. 2 Reassess the patient in an hour. 3 Administer a narcotic antagonist. 4 Assess the patient's neurologic status.

4 Assess the patient's neurologic status. --- Methadone hydrochloride is an opioid analgesic used for pain management. Respiratory depression is an adverse effect of opioid drugs. If the patient's respiration is less than the normal rate, then the nurse would further assess the patient first. If the patient is unresponsive, the nurse would proceed with administering an antagonist. The nurse would not wait and reassess in an hour if an assessment finding was abnormal.

Thirty minutes after surgery the nurse in the postanesthesia care unit (PACU) notes that a patient has a respiratory rate of 6 breaths/min. Which action is the nurse's priority? 1 Administer flumazenil. 2 Prepare intravenous naloxone. 3 Initiate resuscitative measures. 4 Assess the patients' responsiveness.

4 Assess the patients' responsiveness. --- To complete the patient assessment for the planning of suitable nursing care, the PACU nurse would check the patient's responsiveness, then assesses medication administration. The patient's respiratory depression may be from the residual effects of medications used during surgery. Flumazenil is the antidote for benzodiazepine, and naloxone is the antidote for opioids. However, these cannot be used based on anticipation; evidence of application is required. Initiating resuscitative measures before completing the assessment is not the correct nursing practice.

When monitoring a patient for adverse effects related to morphine sulfate, the nurse assesses for stimulation of which response? 1 Circulation 2 Respiratory rate 3 Cough reflex 4 Chemoreceptor trigger zone

4 Chemoreceptor trigger zone --- Morphine sulfate can irritate the gastrointestinal tract, causing stimulation of the chemoreceptor trigger zone in the brain, which in turn causes nausea and vomiting. Opioids do not stimulate circulation. Opioids cause a decrease in respiratory rate, not stimulation. Opioids suppress the cough reflex.

The nurse is assessing a patient who underwent surgery and is prescribed oxycodone. Which assessment finding requires the nurse to take action? 1 Heart rate 90 beats/min 2 Vague feeling of anxiety 3 Respiratory rate 12 breaths/min 4 No bowel movement in 72 hours

4 No bowel movement in 72 hours --- Oxycodone is an opioid drug, which may decrease peristalsis because of its depressive effect on the central and peripheral nervous system, resulting in constipation. Therefore, the nurse would act on the assessment that the patient has not had a bowel movement in 72 hours. The patient may need a laxative at this point and teaching about ways to prevent constipation in the future, such as the use of stool softeners. The heart rate and respiratory rate are within normal limits, and a vague feeling of anxiety can be assessed further after physical problems are treated. The priority is to treat the patient's constipation.

The nurse is caring for a patient who is receiving 20 mg of hydrocodone orally every 4 hours. The drug is to be changed to intravenous (IV) fentanyl. Calculate the equivalent dose of IV fentanyl for a period of 24 hours. Record your answer using one decimal point. Use a leading zero if necessary. ____________ mg

The amount of hydrocodone the patient is receiving for a period of 24 hours = 20 mg × 6 doses per 24 hours = 120 mg per 24 hours. The equianalgesic doses of fentanyl and hydrocodone: 30 mg of oral hydrocodone = 10 mg IV morphine = 0.1 mg of IV fentanyl. So 30 mg of oral hydrocodone = 0.1 mg of fentanyl. 120 mg × 0.1 = 30x mg12 mg/30 mg = xx = 0.4 mgAmount of fentanyl to be given IV for a period of 24 hours (x) = 0.4 mg.