NARCOTICS, NARCOTIC ANTAGONISTS & ANTIMIGRAINE AGENTS

A client with a viral respiratory infection has an intense headache and cough. What drug will best address both of this client's symptoms? A) Codeine B) Hydromorphone C) Ibuprofen D) Acetaminophen

Ans: A Feedback: Codeine is a narcotic drug used for its analgesic and antitussive effects. Hydromorphone, ibuprofen, and acetaminophen do not have antitussive effects.

A nurse is caring for a 6-year-old client after surgery. The child has an order for meperidine 1.8 mg/kg IM every 3 to 4 hour as needed for pain. The child weighs 30 kg and the meperidine is available as 50 mg/mL. What is the correct amount of mL, to one decimal place, that the nurse should administer per dose?

Ans: 1.1 mL Feedback: To calculate the correct amount to be administered, first multiply 1.8 mg times 30 kg (54 mg). Next determine the volume in milliliter that 54 mg is equal to (50 mg: 1 mL as 54 mg: × mL). Solve for × (50× is equal to 54 mg; 54 divided by 50 is equal to 1.08 mL). To one decimal place, 1.08 mL is 1.1 mL.

The nurse is caring for a client experiencing postoperative pain. The client is prescribed 2.5 mg of morphine IV every 2 hours. Morphine is supplied in 10 mg/mL vials. How many mL should the nurse administer? A) 0.25 mL B) 0.5 mL C) 1 mL D) 2.5 mL

Ans: A Feedback: 10 mg = 1 mL and a dose of 2.5 mg is ordered. 10 mg/1 mL: 2.5 mg/X. Cross-multiply to yield 2.5 mg = 10X. Divide each side by 10 to learn the nurse should administer 0.25 mL.

The client in labor receives morphine every 2 hours to manage labor pain. After 22 hours of labor, the woman delivers a healthy neonate. What is the nurse's priority action related to the newborn? A) Monitor for opioid effects. B) Administer naloxone. C) Monitor for withdrawal syndrome. D) Assess for congenital anomaly.

Ans: A Feedback: Morphine, meperidine, and oxymorphone are often used for analgesia during labor. The mother should be monitored closely for adverse reactions, and, if the drug is used during a prolonged labor, the newborn infant should be monitored for opioid effects. Naloxone would only be given if the newborn displays opioid effects. Withdrawal syndrome would not be seen with less than 24 hours of use. Every newborn is assessed for congenital anomalies, but this would not be related to administration of morphine to the mother and so would not be the highest priority.

A postsurgical client has been receiving morphine by patient-controlled analgesic for 2 days. What action by the nurse best addresses potential adverse effects? A) Administering a stool softener as prescribed B) Auscultating the client's lung for adventitious sounds C) Encouraging active range of motion exercises D) Applying calf compressors as prescribed

Ans: A Feedback: Narcotics create a significant risk for constipation, and relevant nursing interventions are required. Respiratory rate must be closely monitored, but there is not a high likelihood of adventitious lung sounds. There is no obvious risk for venous stasis that would require calf compressors. Exercises have general benefits, but do not address the particular adverse effects of morphine.

The nurse receives a prescription for morphine sulfate 8 mg IV every hour as needed for pain. For what client should the nurse question this order? A) A 78-year-old with osteoarthritis B) A 45-year-old, 1-day postoperative mastectomy C) A 28-year-old with a fractured tibia D) A 17-year-old, 1-day postoperative appendectomy

Ans: A Feedback: Older clients are more likely to experience the adverse effects associated with narcotics, including central nervous system, gastrointestinal, and cardiovascular effects. Furthermore, a strong narcotic analgesic would not be indicated for chronic osteoarthritis pain. For both of these reasons, the nurse would question the large dosage of a narcotic. The other clients could appropriately receive morphine 8 mg unless they were smaller than average adults.

A client with a history of migraines has been prescribed sumatriptan and is experiencing relief. What physiologic response is the client most likely experiencing? A) Vasoconstriction of cranial blood vessels B) Increased synthesis and release of endorphins C) Stimulation of A-delta D) Stimulation of C fibers

Ans: A Feedback: Sumatriptan binds to serotonin receptors to cause vasoconstrictive effects on cranial blood vessels. It does not directly influence endorphin levels. Stimulation of A-delta and C fibers causes increased, not decreased, pain levels.

A client who is 84 years old is experiencing chronic lower back that has not responded to NSAIDs. The provider has prescribed a transdermal fentanyl patch. What should the nurse do to ensure safe and effective care? Select all that apply. A) Monitor the client's respiratory status closely. B) Keep the client's bed in the lowest position. C) Ensure the client has access to the call light. D) Monitor the client's temperature before and after administration. E) Avoid administering any other medications while the transdermal patch is in

Ans: A, B, C Feedback: Older clients are more likely to experience the adverse effects associated with these drugs, including respiratory depression and general CNS depression. To prevent falls, the client's bed should be kept in a low position and the client should have ready access to the call light. There is no need to monitor temperature closely when narcotics are given. Other medications are not contraindicated when a fentanyl patch is in place.

The client is brought to the emergency department in respiratory arrest after overdosing on heroin. The person accompanying the client says he has been using heroin for years. After being administered one dose of naloxone, the client begins to breathe spontaneously but remains nonresponsive to stimuli so another dose is prescribed. The nurse should monitor for what signs and symptoms of acute narcotic abstinence syndrome? Select all that apply. A) Tachycardia B) Hypertension C) Vomiting D) Bradypnea E) Sedation

Ans: A, B, C Feedback: The most common adverse effect is an acute narcotic abstinence syndrome that is characterized by nausea, vomiting, sweating, tachycardia, hypertension, tremulousness, and feelings of anxiety. Bradypnea and sedation are not associated with acute narcotic abstinence syndrome.

The nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The client is in pain so the nurse administers 4 mg morphine IV as prescribed. After administering the drug, the PACU nurse calls to say a dose of morphine was given and not documented. What actions should the nurse perform? Select all that apply. A) Ensure naloxone is readily available. B) Inform the client's healthcare provider. C) Administer buprenorphine as prescribed. D) Document the event. E) Monitor the client's respiratory rate closely. F) Arrange for cardiac monitoring.

Ans: A, B, D, E Feedback: The nurse should inform the care team and document this event. Close respiratory monitoring would be necessary, but cardiac monitoring would not likely be required. Naloxone is the drug of choice for treatment of opioid overdose and should be readily available. Buprenorphine hydrochloride is a narcotic-agonist- antagonist and would suppress respirations further.

A client is experiencing pain. What are being stimulated in this client? Select all that apply. A) A-delta fibers B) D-delta sensory nerves C) Mu receptors D) Sigma-receptors E) C fibers

Ans: A, E Feedback: Two small-diameter sensory nerves, A-delta and C fibers, respond to stimulation by generating nerve impulses that produce pain sensations. Largediameter sensory nerves (i.e., A fibers) transmit sensations associated with touch and temperature. Mu-receptors are primarily pain-blocking receptors; sigmareceptors cause papillary dilation and may be responsible for the hallucinations, dysphoria, and psychoses that can occur with narcotic use.

A client with a migraine took a prescribed dose of eletriptan, and 1-hour later, the headache is still intense. The client's spouse calls the clinic and asks the nurse what they should do. What is an appropriate nursing response? A) "Tell them to lie down in a quiet cool room and just wait it out. It will subside." B) "They can take another dose of the drug 2 hours after the initial dose if the headache continues." C) "Give them a dose of an ergot drug if you have it. It will decrease the intensity of the pain." D) "Ibuprofen may increase the action of the triptan.

Ans: B Feedback: A client taking eletriptan to relieve a migraine can take another dose in 2 hours if the headache is not relieved. The combination of ergot drugs with triptans is not indicated because of the vasoconstriction caused by both. The client will not get relief by "waiting it out." Ibuprofen is an antiinflammatory that does not affect the mechanism associated with migraines.

The nurse administers hydromorphone IV to the postoperative client as prescribed. What is the best method for the nurse to evaluate the client's response to the medication? A) Observe the client's behavior without the client's awareness, 30 minutes after administration. B) Use a pain assessment tool before and 30 minutes after administration. C) Assess the client's vital signs before and after drug administration. D) Ask the client if the medication has been effective.

Ans: B Feedback: A standard pain assessment tool should be used both pre- and postanalgesia. This type of quantitative data are more accurate than asking the client a yes/no question about the effectiveness of the medication. The nurse should observe the client's response, but this does not provide the most accurate assessment data. Similarly, vital signs should be monitored, but trends do not necessarily demonstrate effectiveness.

A palliative client is experiencing intense cancer pain that requires large and frequent doses of narcotics. The provider has prescribed methylnaltrexone to address the client's resulting constipation. What is a nursing responsibility related to methylnaltrexone administration? A) Administering one 2-mg tablet after each meal, as prescribed B) Administering the medication by daily subcutaneous injection C) Ensuring that the client's IV access is patent and reliable D) Encouraging fluid intake as much as possible

Ans: B Feedback: Methylnaltrexone is only given by subcutaneous injection once each day. Fluid intake greatly helps the treatment of constipation, but this is not directly related to methylnaltrexone administration.

The nurse is caring for a client who has experienced little pain relief. The care team is considering the use of pentazocine. What aspect of the client's current status would necessitate cautious use of pentazocine? A) The client has diverticulosis. B) The client had a myocardial infarction 18 months ago. C) The client takes over-the-counter laxatives and stool softeners regularly. D) The client has smoked cigarettes for four decades.

Ans: B Feedback: Pentazocine must be administered cautiously to clients with known heart disease because the drug may cause cardiac stimulation including arrhythmias, hypertension, and increased myocardial oxygen consumption, which could lead to angina, myocardial infarction, or congestive heart failure. The client's gastrointestinal function would not require cautious use. Smoking has a negative effect on the client's cardiac function but does not preclude the use of pentazocine.

The nurse is preparing to administer an ergot drug to a client for the first time. What other medication that the client is taking should cause the nurse to question the order? A) An oral hypoglycemic B) A beta adrenergic blocker C) An oral contraceptive D) A selective serotonin reuptake inhibitors (SSRIs)

Ans: B Feedback: The concurrent use of beta blockers and ergot preparations increases the client's risk for peripheral ischemia and gangrene. This combination should be avoided. There is no indication for concern with the use of antidiabetic agents, SSRIs, and oral contraceptives with these drugs.

The nurse is caring for a client who is receiving morphine via patientcontrolled analgesia (PCA). In addition to pain assessment, what assessments should the nurse prioritize? A) Apical heart rate and temperature B) Level of consciousness and respiratory rate C) Respiratory rate and fluid balance D) Urine output and inspection of the IV site

Ans: B Feedback: The nurse should assess respiratory rate and level of consciousness because respiratory depression and sedation are adverse effects of opioid analgesics. None of the other assessment parameters is as likely to be volatile as LOC and respiratory rate.

What order for naloxone would be appropriate for the nurse to administer for reversal of opioid effects? A) 1 mg IV repeat every 2 to 3 minutes B) 5 mg IV repeat every 5 minutes C) 0.1 mg IV repeat every 2 to 3 minutes D) 0.4 mg IV repeat every 3 minutes

Ans: C Feedback: 0.1 to 0.2 mg is given IV and then repeated every 2 to 3 minutes for reversal of opioid effects. If the client has overdosed on opioids, the dose would be much larger: 0.4 to 2 mg every 2 to 3 minutes.

A client has been taking morphine PO for several months following a back injury. The care team is working with the client to wean the client off morphine. The client reports he is getting minimal relief from the pain with the new nonopioid medication he is receiving. What should the nurse suspect is causing this client's pain? A) Administer a higher dose of morphine, as prescribed. B) Assess the client for further signs of addiction. C) Assess the client for further signs of withdrawal syndrome. D) Monitor the client for hypersensitivity

Ans: C Feedback: Caution should be used in cases of physical dependence on a narcotic because a withdrawal syndrome may be precipitated, the narcotic antagonistic properties can block the analgesic effect, and so intensify the pain. It is important to differentiate between addiction and dependence because addiction generally does not occur in clients receiving narcotics for medical reasons. There is no indication of a hypersensitivity reaction. Giving a higher dose of the opioid would eliminate the progress made to date on weaning the client from the narcotic, so attempts should be made to avoid this intervention.

The nurse is providing client teaching about a prescribed opioid analgesic. When monitoring the client for potential adverse effects, what assessment should the nurse prioritize? A) Coordination B) Visual acuity C) Blood pressure D) Heart rhythm

Ans: C Feedback: Orthostatic hypotension is commonly seen in association with some narcotics. For most clients, changes in blood pressure are most likely than dysrhythmias, ataxia, and changes is vision.

A hospital client's pain is rated at 9/10, and the nurse is preparing to administer 4 mg hydromorphone PO as prescribed. What are the appropriate interventions by the nurse prior to administering the medication? A) Ensure the client is aware of NSAID alternatives to this narcotic. B) Assess the client's apical heart rate for 1 minute. C) Assess the client's baseline respiratory rate. D) Ensure that there is naloxone available at the bedside.

Ans: C Feedback: The nurse should check the client's rate, depth, and rhythm of respirations before each dose. Bradycardia would contraindicate safe use, but this does not necessarily require 1-minute auscultation of a client's heart rate. Naloxone should be available but does not need to be at the client's bedside. Teaching about alternatives would depend on the client's status, the current prescriptions, and the client's pain level.

What client characteristic may contraindicate the use of tramadol for the treatment of a client's pain following traumatic injuries? A) The client has developed a wound infection and is at risk of sepsis. B) The client is 48 hours postorthopedic surgery. C) The client has a history of crack cocaine addiction. D) The client required a transfusion of packed red blood cells on admission.

Ans: C Feedback: The use of tramadol is generally limited in clients who have a history of addiction. Infection, surgery, and transfusions would not necessarily preclude the use of this narcotic.

A client with migraine headaches is changed from an ergot to a prescription for a triptan. The nurse has provided health education related to the new medication. What statement would indicate that the client has a clear understanding of the new medication? A) "I'll keep a close watch for any changes in the color of my urine." B) "I can resume my normal driving habits because this medication isn't sedating." C) "I shouldn't experience as many adverse effects from my new medication." D) "I can take my medication every hour when I have a headache."

Ans: C Feedback: Triptans are a new class of selective serotonin receptor blockers that cause vasoconstriction; they are not associated with as many systemic adverse effects as experienced in ergot therapy. Although adverse effects are fewer than those associated with ergot therapy, triptans can still cause dizziness, feelings of strangeness, and vertigo, so the client should not drive while taking the drug. Triptans are often only taken once due to prolonged half-lives, but some may be repeated in 2 to 4 hours if the headache does not subside. Urine discoloration is not a noted adverse effect.

The pediatric nurse is providing care for several clients who are experiencing pain. The nurse should anticipate that clients may be ordered what narcotic analgesics? Select all that apply. A) Transdermal fentanyl B) Methadone C) Morphine D) Meperidine E) Hydrocodone

Ans: C, D, E Feedback: Narcotics that have an established pediatric dose include codeine, fentanyl (but not the transdermal form), hydrocodone, meperidine, and morphine. Methadone is not recommended as an analgesic in children.

A client is in the hospital recovering from surgery. The client's adult child tells the nurse they are concerned their parent will overdose on morphine because they keep pressing the button on the client-controlled anesthesia (PCA) pump. In addition to reassessing the client's pain, what is the nurse's best response? A) "I'll teach you some techniques to take their focus off the pain so they don't press the button so often." B) "If they follow the directions given, that will not happen." C) "I'll come and teach them again how to use the PCA safely and effectively." D) "The device has maximum limits programmed, so your parent cannot get more than a specific amount."

Ans: D Feedback: A PCA system using morphine provides a baseline, constant infusion of morphine and gives the client control of the system to add bolus doses of morphine if the client believes that pain is not being controlled. The system prevents overdose by locking out extra doses until a specific period of time has elapsed. Offering to teach relaxation techniques to the family member does not address the expressed concern

The nurse is preparing to administer morphine IV to a client with multiple trauma. Before administering the morphine, what common adverse effect should the nurse inform the client about? A) Paresthesia in lower extremities B) Occipital headache C) Photophobia D) Drowsiness

Ans: D Feedback: Common adverse effects include dizziness, drowsiness, and visual changes. Morphine does not commonly cause paresthesia in the lower extremities, an occipital headache, or photophobia.

A client has been experiencing severe pain and is being treated with narcotics. What should the nurse include in the plan of care as a desirable and measurable outcome for this client? A) Reduced periods of time between requests for medication B) Reduced resting heart rate C) Maintaining one position for a prolonged period of time D) Increased independence with AM care

Ans: D Feedback: Monitor client response to the drug (e.g., relief of pain, sedation). When pain is being adequately managed with opioid therapy, a desirable and measurable outcome would be that the client is able to be more autonomous in providing care in the morning. Shorter periods between requests for medication may suggest that pain is becoming worse, not better. Clients in pain tend not to move for fear of exacerbating the pain, so lack of movement can be an indication the client is in pain. Pain tends to increase an individual's heart rate, but a reduction is heart rate does not necessarily indicate successful pain management.

The nurse is caring for a client whose pain is being treated with pentazocine. What would be an appropriate nursing diagnosis for this client's care plan? A) Diarrhea related to adverse gastrointestinal effects B) Risk for autonomic dysreflexia related to central nervous system depression C) Risk for infection related to immune system depression D) Impaired gas exchange related to respiratory depression

Ans: D Feedback: Nursing diagnoses may include impaired gas exchange related to respiratory depression. The drug is more likely to cause constipation due to slowing of the GI tract instead of diarrhea. The drug has no effect on immune function. Autonomic dysreflexia is not caused by CNS depression and is limited to clients with spinal cord injuries.

A geriatric client received a narcotic analgesic before leaving the postanesthesia care unit to return to the regular unit. What is the priority nursing intervention for the nurse receiving the client on the regular unit? A) Maintain the head of the client's bed at ≥ 45°. B) Encourage fluid intake. C) Create a restful, dark, quiet environment. D) Put side rails up and place bed in low position.

Ans: D Feedback: Older clients are more susceptible to the central nervous system effects of narcotics; it is important to ensure their safety by using side rails and placing the bed in the low position in case the client tries to get up unaided. Postoperative clients are allowed nothing by mouth until bowel function returns so an oral medication or encouraging fluids would not be appropriate. This client will require careful observation for respiratory depression, so a dark room would be unsafe. There is no need to keep the head of the client's bed raised.

A client experiences short-lived, intense headaches that tend to occur in cycles, often with lengthy periods of remission. What medication is most likely to meet this client's needs? A) Almotriptan B) Frovatriptan C) Naratriptan D) Sumatriptan

Ans: D Feedback: Sumatriptan is approved for the treatment of cluster headaches in adults. No other triptans are approved for treatment of cluster headaches.

The healthcare provider prescribes codeine 20 mg PO q4h as an adjunctive therapy to a client's NSAID. What is the nurse's best action? A) Contact the care provider to question the dose. B) Contact the care provider to question the frequency of administration. C) Contact the care provider to question concurrent use of an NSAID and codeine. D) Administer the medication as prescribed and monitor the client's pain.

Ans: D Feedback: The correct dosage for codeine administered for pain by mouth is 15 to 60 mg q4-6h. Narcotics and NSAIDs can be safely administered at the same time. Consequently, there is no apparent need to question this order.

The nurse administers morphine 15 mg oral solution to a client with cancer pain at 09:30. What time should the nurse reassess the client for peak analgesic effect? A) 09:45 B) 10:00 C) 10:30 D) 11:00

Ans: D Feedback: With oral administration, peak activity occurs in about 60 minutes. The duration of action is 5 to 7 hours.