Lehne's Ch 28: Opioid Analgesics, Opioid Antagonists, and Nonopioid Centrally Acting Analgesics

A nurse is administering morphine sulfate to a postoperative patient. Which are appropriate routine nursing actions when giving this drug? (Select all that apply.) a. Counting respirations before and after giving the medication b. Encouraging physical activity and offering increased fluids c. Monitoring the patient's blood pressure closely for hypertension d. Palpating the patient's lower abdomen every 4 to 6 hours e. Requesting an order for methylnaltrexone [Relistor] to prevent constipation

a, b, d a. Counting respirations before and after giving the medication b. Encouraging physical activity and offering increased fluids d. Palpating the patient's lower abdomen every 4 to 6 hours Respiratory depression, constipation, and urinary retention are common adverse effects of opioid analgesics. It is important to count respirations before giving the drug and periodically thereafter to make sure that respiratory depression has not occurred. Increased physical activity, increased fluid intake, and increased fiber help alleviate constipation. It is important to assess the patient's abdomen and palpate the bladder to make sure that urinary retention has not occurred. Patients taking morphine often experience hypotension, not hypertension. Methylnaltrexone is given as a last resort to treat constipation, because it blocks mu receptors in the intestine.

A patient with chronic pain has a fentanyl patch applied to his right shoulder. The patient reports that his arm hurts and he requests a warm pack to apply to the area. Which statement by the nurse is correct? a. "Putting a warm pack on the area where the fentanyl patch is located could accelerate fentanyl release." b. "Your arm probably hurts because of the fentanyl patch." c. "I can remove your patch and reapply it after you are done with the warm pack." d. "The fentanyl patch is heat resistant, so I will get you a warm pack."

a. "Putting a warm pack on the area where the fentanyl patch is located could accelerate fentanyl release."

A patient will receive buprenorphine [Butrans] as a transdermal patch for pain. What is important to teach this patient about the use of this drug? a. Avoid prolonged exposure to the sun. b. Cleanse the site with soap or alcohol. c. Remove the patch daily at bedtime. d. Remove hair by shaving before applying the patch.

a. Avoid prolonged exposure to the sun. Patients using the buprenorphine transdermal patch should be cautioned against heat, heating pads, hot baths, saunas, and prolonged sun exposure. The skin should be cleaned with water only. The patch should stay on for 7 days before a new patch is applied. Patients should remove hair by clipping, not shaving.

A patient who has developed opioid tolerance will experience which effect? a. Decreased analgesic effect b. Decreased constipation c. Increased euphoria d. Increased respiratory depression

a. Decreased analgesic effect Patients who develop tolerance to opioids will develop tolerance to its analgesic, euphoric, and sedative effects and will also develop tolerance to respiratory depression. Very little tolerance develops to constipation.

A patient asks the nurse what can be given to alleviate severe, chronic pain of several months' duration. The patient has been taking oxycodone [OxyContin] and states that it is no longer effective. The nurse will suggest discussing which medication with the provider? a. Fentanyl [Duragesic] transdermal patch b. Hydrocodone [Vicodin] PO c. Meperidine [Demerol] PO d. Pentazocine [Talwin] PO

a. Fentanyl [Duragesic] transdermal patch Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist-antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome

A nurse is preparing a pediatric patient for surgery and is teaching the patient and the child's parents about the use of the patient-controlled analgesia pump. The parents voice concern about their child receiving an overdose of morphine. What will the nurse do? a. Instruct the parents not to activate the device when their child is sleeping. b. Reassure the parents that drug overdose is not possible with PCA. c. Suggest that the child use the PCA sparingly. d. Tell the patient that the pump can be programmed for PRN dosing only.

a. Instruct the parents not to activate the device when their child is sleeping. The nurse should instruct parents not to activate the PCA when their child is sleeping because that can lead to drug overdose. Postoperative pain should be treated appropriately with medications that are effective. Nonopioid medications are not sufficient to treat postoperative pain. Patients should be encouraged to use the PCA as needed so that pain can be controlled in a timely fashion. PRN dosing is not as effective as dosing that is continuous, so a basal dose should be given as well as a PRN dose.

Which agent is most likely to cause serious respiratory depression as a potential adverse reaction? a. Morphine [Duramorph] b. Pentazocine [Talwin] c. Hydrocodone [Lortab] d. Nalmefene [Revex]

a. Morphine [Duramorph] Morphine is a strong opioid agonist and as such has the highest likelihood of causing respiratory depression. Pentazocine, a partial agonist, and hydrocodone, a moderate to strong agonist, may cause respiratory depression, but they do not do so as often or as seriously as morphine. Nalmefene, an opioid antagonist, would be used to reverse respiratory depression with opioids.

A postoperative patient has an epidural infusion of morphine sulfate [Astramorph]. The patient's respiratory rate declines to 8 breaths per minute. Which medication would the nurse anticipate administering? a. Naloxone [Narcan] b. Acetylcysteine [Mucomyst] c. Methylprednisolone [Solu-Medrol] d. Protamine sulfate

a. Naloxone [Narcan] Naloxone is a narcotic antagonist that can reverse the effects, both adverse and therapeutic, of opioid narcotic analgesics.

The nurse watches for which electrocardiogram changes in the patient receiving methadone? a. Prolonged QT interval b. Prolonged PR interval c. Increased heart rate d. Elevated T waves

a. Prolonged QT interval Methadone prolongs the QT interval and may pose a risk of potentially fatal dysrhythmias. Torsades de pointes has developed in patients taking 65 to 400 mg/day.

A patient has been taking methadone [Dolophine] for 5 months to overcome an opioid addiction. The nurse should monitor the patient for which of the following electrocardiographic changes? a. Prolonged QT interval b. Prolonged P-R interval c. AV block d. An elevated QRS complex

a. Prolonged QT interval Methadone prolongs the QT interval. It does not prolong the P-R interval, cause AV block, or produce an elevated QRS complex.

The nurse recognizes that the primary indication for the administration of morphine is to do what? a. Relieve pain b. Reduce anxiety c. Treat left ventricular failure d. Decrease level of consciousness

a. Relieve pain The principal indication for morphine is relief of moderate to severe pain. The drug can relieve postoperative pain, the chronic pain of cancer, and pain associated with labor and delivery. In addition, morphine can be used to relieve pain of myocardial infarction and dyspnea associated with left ventricular failure and pulmonary edema. Morphine may also be administered before surgery for sedation and reduction of anxiety.

After surgery, a patient has morphine prescribed for postoperative pain. It is most important for the nurse to make which assessment? a. Respiratory rate b. Heart rate c. Pain level d. Constipation

a. Respiratory rate

After surgery, a patient has morphine prescribed for postoperative pain. It is most important for the nurse to make which assessment? a. Respiratory rate b. Heart rate c. Pain level d. Constipation

a. Respiratory rate

Which side effects of opioid analgesics can have therapeutic benefits? (Select all that apply.) a. Biliary colic b. Cough suppression c. Suppression of bowel motility d. Urinary retention e. Vasodilation

b, c, e b. Cough suppression c. Suppression of bowel motility e. Vasodilation Individual effects of morphine may be beneficial, detrimental, or both. Cough suppression is usually beneficial; suppression of bowel motility and vasodilation can be either beneficial or detrimental. Biliary colic and urinary retention are always detrimental side effects.

The healthcare provider orders oxycodone [Roxicodone] oral suspension 10 mg PO every 4 hours PRN. The medication available is oxycodone [Roxicodone] 20 mg/mL. How many mL will the nurse administer? a. 0.25 mL b. 0.5 mL c. 1 mL d. 2 mL

b. 0.5 mL

A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse, "Why am I receiving codeine? I don't have any pain." The nurse's response is based on the knowledge that codeine also has which effect? a. Immunostimulant b. Antitussive c. Expectorant d. Decongestant

b. Antitussive Codeine provides analgesic and antitussive therapeutic effects.

The nurse would question the administration of morphine in the patient with a history of which condition? a. Diabetes b. Asthma c. Anorexia d. Cancer

b. Asthma Morphine should be used with caution in patients with asthma, emphysema, kyphoscoliosis, chronic cor pulmonale, and extreme obesity. Caution is also needed in patients taking other drugs that can depress respiration (e.g., barbiturates, benzodiazepines, general anesthetics). Morphine is indicated in the treatment of severe pain associated with cancer.

Clonidine is prescribed for the treatment of a patient's severe pain. The nurse is aware that for treatment of pain, this drug should be administered by which route? a. Oral b. Epidural c. Intravenous d. Transdermal

b. Epidural Clonidine has two approved applications: treatment of hypertension and relief of severe pain. As a means of relieving severe pain, clonidine is administered by way of continuous epidural infusion.

The nurse is planning care for a patient receiving morphine sulfate [Duramorph] by means of a patient-controlled analgesia (PCA) pump. Which intervention may be required because of a potential adverse effect of this drug? a. Administering a cough suppressant b. Inserting a Foley catheter c. Administering an antidiarrheal d. Monitoring liver function tests

b. Inserting a Foley catheter Morphine can cause urinary hesitancy and urinary retention. If bladder distention or inability to void is noted, the prescriber should be notified.

A patient reports having taken morphine for the past 6 months. Which medication, if ordered by the physician, should the nurse question? a. Promethazine [Phenergan] b. Pentazocine [Talwin] c. Methylnaltrexone [Relistor] d. Dextromethorphan [Delsym]

b. Pentazocine [Talwin]

A patient reports having taken morphine for the past 6 months. Which medication, if ordered by the physician, should the nurse question? a. Promethazine [Phenergan] b. Pentazocine [Talwin] c. Methylnaltrexone [Relistor] d. Dextromethorphan [Delsym]

b. Pentazocine [Talwin] Pentazocine is an agonist-antagonist opioid. If pentazocine is given to a patient who is physically dependent on a pure opioid agonist such as morphine, withdrawal or abstinence syndrome will occur.

In preparing an inservice about opioids, the nurse includes which problem as the most serious adverse effect? a. Suppressed cardiac automaticity b. Respiratory depression c. Profound sedation d. Hyperthermia

b. Respiratory depression Respiratory depression is the most serious adverse effect of the opioids. At equianalgesic doses, all of the pure opioid agonists depress respiration to the same extent. Death following overdose is almost always a result of respiratory arrest.

The nurse is working on a postoperative unit in which pain management is part of routine care. Which statement is the most helpful in guiding clinical practice in this setting? a. At least 30% of the U.S. population is prone to drug addiction and abuse. b. The development of opioid dependence is rare when opioids are used for acute pain. c. Morphine is a common drug of abuse in the general population. d. The use of PRN (as needed) dosing provides the most consistent pain relief without risk of addiction.

b. The development of opioid dependence is rare when opioids are used for acute pain. The development of dependence on or addiction to opioids as a result of clinical exposure is extremely rare. In fact, some estimate that only 25% of patients receive doses of opioids that are sufficient to relieve suffering. Only about 8% of the population is estimated to be prone to drug abuse. Morphine is a drug of abuse, but this fact is not helpful in guiding clinical practice. A patient-controlled analgesia (PCA) pump provides the most consistent pain relief, better than PRN and fixed-dosing schedules.

A patient with moderate to severe chronic pain has been taking oxycodone [OxyContin] 60 mg every 6 hours PRN for several months and tells the nurse that the medication is not as effective as before. The patient asks if something stronger can be taken. The nurse will contact the provider to discuss: a. administering a combination opioid analgesic/acetaminophen preparation. b. changing the medication to a continued-release preparation. c. confronting the patient about drug-seeking behaviors. d. withdrawing the medication, because physical dependence has occurred.

b. changing the medication to a continued-release preparation. Oxycodone is useful for moderate to severe pain, and a continued-release preparation may give more continuous relief. Dosing is every 12 hours, not PRN. A combination product is not recommended with increasing pain, because the nonopioid portion of the medication cannot be increased indefinitely. This patient does not demonstrate drug-seeking behaviors. Physical dependence is not an indication for withdrawing an opioid, as long as it is still needed; it indicates a need for withdrawing the drug slowly when the drug is discontinued.

The nurse is teaching a patient with cancer about a new prescription for a fentanyl [Sublimaze] patch, 25 mcg/hr, for chronic back pain. Which statement is the most appropriate to include in the teaching plan? a. "You will need to change this patch every day, regardless of your pain level." b. "This type of pain medication is not as likely to cause breathing problems." c. "With the first patch, it will take about 24 hours before you feel the full effects." d. "Use your heating pad for the back pain. It will also improve the patch's effectiveness."

c. "With the first patch, it will take about 24 hours before you feel the full effects." Full analgesic effects can take up to 24 hours to develop with fentanyl patches. Most patches are changed every 72 hours.

The nurse correlates orthostatic hypotension resulting from opioid administration with which cause? a. Decreased heart rate b. Impaired contractility c. Dilation of peripheral veins d. Elevated circulating catecholamines

c. Dilation of peripheral veins Morphine-like drugs lower blood pressure by blunting the baroreceptor reflex and by dilating peripheral arterioles and veins. Peripheral vasodilation results primarily from morphine-induced release of histamine. Hypotension is mild in the recumbent patient but can be substantial when the patient stands up.

A nurse administers naloxone [Narcan] to a postoperative patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication? a. Drowsiness b. Tics and tremors c. Increased pain d. Nausea and vomiting

c. Increased pain Naloxone reverses the effects of narcotics. Although the patient's respiratory status will improve after administration of naloxone, the pain will be more acute.

The nurse prepared to administer which drug to the patient with suspected opioid overdose? a. Glucose b. Caffeine c. Naloxone d. Tramadol

c. Naloxone

A patient who has biliary colic reports a pain level of 8 on a 1 to 10 pain scale with 10 being the most severe pain. The patient has an order for ibuprofen as needed for pain. Which action by the nurse is correct? a. Administer the ibuprofen as ordered. b. Contact the provider to discuss nonpharmacologic pain measures. c. Request an order for meperidine [Demerol]. d. Request an order for morphine sulfate.

c. Request an order for meperidine [Demerol]. Opioids can induce spasm of the common bile duct and can cause biliary colic. For patients with existing biliary colic, morphine may intensify the pain. It is important to treat pain, however, and certain opioids, such as meperidine, which cause less smooth muscle spasm, may be given. Ibuprofen is used for mild to moderate pain and is not appropriate for this patient. Nonpharmacologic methods are appropriate when used as adjunctive therapy with an opioid.

A patient is admitted with the following vital signs: 37.6 °C, P 96, R 16, 140/90 mm Hg. If the patient is scheduled for a dose of opioid, which of the vital sign parameters would require an immediate intervention? a. Pulse rate of 110 b. Temperature of 38 °C c. Respiratory rate of 10 d. Blood pressure of 160/86 mm Hg

c. Respiratory rate of 10 The drug should be withheld and the physician notified if respiratory rate is at or below 12 breaths per minute, if blood pressure is significantly below the pretreatment value, or if pulse rate is significantly above or below the pretreatment value.

A patient with cancer has been taking an opioid analgesic four times daily for several months and reports needing increased doses for pain. What will the nurse tell the patient? a. PRN dosing of the drug may be more effective. b. The risk of respiratory depression increases over time. c. The patient should discuss increasing the dose with the provider. d. The patient should request the addition of a benzodiazepine to augment pain relief.

c. The patient should discuss increasing the dose with the provider. This patient is developing tolerance, which occurs over time and is evidenced by the need for a larger dose to produce the effect formerly produced by a smaller dose. This patient should be encouraged to request an increased dose. PRN dosing is less effective than scheduled, around-the-clock dosing. The risk of respiratory depression decreases over time as patients develop tolerance to this effect. Benzodiazepines are CNS depressants and should not be given with opioids, because they increase the risk of oversedation.

The nurse includes which information in an inservice about the therapeutic effects of agonist-antagonists? a. These drugs relieve pain better than opioids. b. These drugs have greater potential for abuse than opioids. c. These drugs produce less respiratory depression than opioids. d. These drugs have minimal side effects when compared with opioids.

c. These drugs produce less respiratory depression than opioids.

The nurse closely monitors the patient receiving morphine and a tricyclic antidepressant for which manifestations of drug interactions? a. Bradycardia b. Hyperpyrexia c. Urinary retention d. Respiratory depression

c. Urinary retention Anticholinergic drugs (e.g., antihistamines, tricyclic antidepressants, atropine-like drugs) can exacerbate morphine-induced constipation and urinary retention. Hyperpyrexia is associated with the combination of meperidine (a morphine-like drug) with a monoamine oxidase (MAO) inhibitor. Respiratory depression is exacerbated when an opioid is given with another barbiturate.

A woman in labor receives meperidine [Demerol] for pain. The nurse caring for the infant will observe the infant closely for: a. congenital anomalies. b. excessive crying and sneezing. c. respiratory depression. d. tremors and hyperreflexia.

c. respiratory depression. Use of morphine or other opioids during delivery can cause respiratory depression in the neonate, because the drug crosses the placenta. Infants should be monitored for respiratory depression and receive naloxone if needed. Opioids given during delivery do not contribute to birth defects in the newborn. Excessive crying and sneezing and tremors and hyperreflexia are signs of neonatal opioid dependence, which occurs with long-term opioid use by the mother during pregnancy and not with short-term use of these drugs during labor.

The nurse would recommend treatment with transdermal fentanyl for a patient with which issue? a. Postoperative pain after gastric bypass b. Initial treatment for migraine headaches c. Severe pain caused by cancer metastasis to bone d. Intermittent lower back pain associated with lumbar strain

d. Intermittent lower back pain associated with lumbar strain Transdermal fentanyl is indicated only for persistent severe pain in patients who are already opioid tolerant. Use in nontolerant patients can cause fatal respiratory depression. The patch should not be used in children under 2 years of age or in anyone younger than 18 who weighs less than 110 lb. Also, the patch should not be used for postop pain, intermittent pain, or pain that responds to a less powerful analgesic

A postoperative patient who received an intravenous infusion of morphine has a respiratory rate of 8 breaths per minute and is lethargic. Which as-needed medication should the nurse administer to the patient? a. Methadone [Dolophine] b. Nalbuphine [Nubain] c. Tramadol [Ultram] d. Naloxone [Narcan]

d. Naloxone [Narcan]

In reviewing admission orders for a patient with a myocardial infarction, the nurse would question an order for which medication? a. Aspirin b. Morphine c. Butorphanol d. Pentazocine

d. Pentazocine Pentazocine increases cardiac work. Accordingly, a pure agonist (e.g., morphine) is preferred to pentazocine for relieving pain in patients with myocardial infarction.

A patient who has had abdominal surgery has been receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. The nurse assesses the patient and notes that the patient's pupils are dilated and that the patient is drowsy and lethargic. The patient's heart rate is 84 beats per minute, the respiratory rate is 10 breaths per minute, and the blood pressure is 90/50 mm Hg. What will the nurse do? a. Discuss possible opiate dependence with the patient's provider. b. Encourage the patient to turn over and cough and take deep breaths. c. Note the effectiveness of the analgesia in the patient's chart. d. Prepare to administer naloxone and possibly ventilatory support.

d. Prepare to administer naloxone and possibly ventilatory support. Opioid toxicity is characterized by coma, respiratory depression, and pinpoint pupils. Although pupils are constricted initially, they may dilate as hypoxia progresses, which also causes blood pressure to drop. This patient has a respiratory rate of fewer than 12 breaths per minute, dilated pupils, and low blood pressure; the patient also is showing signs of central nervous system (CNS) depression. The nurse should prepare to give naloxone and should watch the patient closely for respiratory collapse. Patients with opioid dependence show withdrawal symptoms when the drug is discontinued. When postoperative patients have adequate analgesia without serious side effects, encouraging patients to turn, cough, and breathe deeply is appropriate. This patient is probably relatively pain free, but providing emergency treatment is the priority.

A patient takes oxycodone [OxyContin] 40 mg PO twice daily for the management of chronic pain. Which intervention should be added to the plan of care to minimize the gastrointestinal adverse effects? a. The patient should take an antacid with each dose. b. The patient should eat foods high in lactobacilli. c. The patient should take the medication on an empty stomach. d. The patient should increase fluid and fiber in the diet.

d. The patient should increase fluid and fiber in the diet.

A patient is brought to the emergency department by friends, who report finding the patient difficult to awaken. The friends report removing two fentanyl transdermal patches from the patient's arm. On admission to the emergency department, the patient has pinpoint pupils and a respiratory rate of 6 breaths per minute. A few minutes after administration of naloxone, the respiratory rate is 8 breaths per minute and the patient's pupils are dilated. The nurse recognizes these symptoms as signs of: a. a mild opioid overdose. b. decreased opioid drug levels. c. improved ventilation. d. worsening hypoxia.

d. worsening hypoxia. The classic triad of symptoms of opioid overdose are coma, respiratory depression, and pinpoint pupils. The pupils may dilate as hypoxia worsens, and this symptom, along with continued respiratory depression (fewer than 12 breaths per minute), indicates worsening hypoxia. Fentanyl is a strong opioid, so this is not likely to be a mild overdose, because the patient was wearing two patches. Fentanyl continues to be absorbed even after the patches are removed because of residual drug in the skin, so the drug levels are not likely to be decreasing. The patient does not have improved ventilation, because the respiratory rate is still fewer than 12 breaths per minute.

A patient with chronic pain has been receiving morphine sulfate but now has decreased pain. The prescriber changes the medication to pentazocine [Talwin]. The nurse will monitor the patient for: a. euphoria. b. hypotension. c. respiratory depression. d. yawning and sweating.

d. yawning and sweating. Pentazocine is an agonist-antagonist opioid, and when given to a patient who is physically dependent on morphine, it can precipitate withdrawal. Yawning and sweating are early signs of opioid withdrawal. Pentazocine does not produce euphoria, hypotension, or respiratory depression.