Pharmacology- Chapter 26: Narcotics, Narcotic Antagonists, and Antimigraine Agents

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?

"I shouldn't experience as many adverse effects from my new medication." Response 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.

A client with a migraine took a prescribed dose of eletriptan, and 1 hour later, the headache is still intense. The client's husband calls the clinic and asks the nurse what they should do. What is an appropriate nursing response?

"She can take another dose of the drug 2 hours after the initial dose if the headache continues." Response 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 anti-inflammatory that does not affect the mechanism associated with migraines.

A client is admitted to the hospital for surgery. After the client returns to the floor, the client's daughter tells the nurse she is concerned that her mother will overdose on morphine because she keeps pressing the button on her client-controlled anesthesia (PCA) pump. In addition to reassessing the client's pain, what is the nurse's best response?

"The device has maximum limits programmed, so your mother cannot get more than a specific amount." Response 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.

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?

-Monitor the client's respiratory status closely -Keep the client's bed in the lowest position -Ensure that the client has access to the call light Response 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.

What order for naloxone would be appropriate for the nurse to administer for reversal of opioid effects?

0.1 mg IV repeat every 2 to 3 minutes Response 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.

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?

0.25 mL Response 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.

A hospital client is reporting pain, and the provider has prescribed 3 mg hydromorphone SC. The medication is available in single-use vials of 10 mg/1 mL. How many mL of hydromorphone should the nurse draw up?

0.3 mL Response Feedback: The nurse should divide 3 mg by 10 mg/mL, resulting in 0.3 mL.

The nurse administers morphine 15 mg oral solution to a client with cancer pain at 09:30. When should the nurse reassess the client for peak effect? a.09:45 b.10:00 c.10:30 d.11:00

11:00 Response Feedback: With oral administration, peak activity occurs in about 60 minutes. The duration of action is 5 to 7 hours.

The nurse receives a prescription for morphine sulfate 8 mg IV every hour as needed for pain. For which client would the nurse need to question this order?

A 78-year-old with osteoarthritis Response 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.

For which clients would the use of narcotic agonists-antagonists be appropriate?

A client injured in a motor vehicle accident who rates his pain at 7/10 A client who is in the second stage of labor A client who will undergo general anesthesia for orthopedic surgery Response Feedback: These drugs have three functions: (1) relief of moderate to severe pain, (2) adjuncts to general anesthesia, and (3) relief of pain during labor and birth. For a pregnant client, alternatives should be trialed before using narcotic agonists-antagonists due to the risks associated with fetal exposure. A client whose respiratory rate is too low for narcotic administration should not be given an agonist-antagonist because it will cause further respiratory depression.

A client is experiencing pain. What are being stimulated in this client?

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

The health care provider prescribes codeine 20 mg PO q4h as an adjunctive therapy to a client's NSAID. What is the nurse's best action?

Administer the medication as prescribed, and monitor the client's pain Response Feedback:The correct dosage for codeine administered for pain by mouth is 15 to 60 mg q 4 to 6 hour. Narcotics and NSAIDs can be safely administered at the same time. Consequently, there is no apparent need to question this order.

A client's postsurgical pain is severe and persistent, and the client states that recent doses of morphine IV have "helped only a little bit." The client has a PRN dose of morphine available and wants to receive the medication, but the client's respiratory rate is 14 breaths/minute. What is the nurse's best action?

Administer the morphine as prescribed and monitor the client's respiratory status closely Response Feedback: A respiratory rate of 14 breaths per minute is lower than expected, but is not low enough to warrant withholding a client's medication. The nurse should give the medication and monitor the client closely. There is no clear need to contact the provider.

A postsurgical client has been receiving morphine by patient-controlled analgesic for 2 days. What action by the nurse best addresses potential adverse effects?

Administering a stool softener as prescribed Response 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.

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?

Administering the medication by daily subcutaneous injection Response 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.

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?

Assess the client for further signs of withdrawal syndrome. Response 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 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 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?

Beta adrenergic blocker Response 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.

A client with a viral respiratory infection has an intense headache and cough. What drug will best address both of this client's symptoms?

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

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?

Ensure naloxone (Narcan) is readily available. Inform the client's health care provider Monitor the client's respiratory rate closely Document the event Response 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.

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?

Impaired gas exchange related to respiratory depression Response 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 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?

Increased independence with AM care Response 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 who is receiving morphine via patient-controlled analgesia (PCA). In addition to pain assessment, what assessments should the nurse prioritize?

Level of consciousness and respiratory rate Response 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.

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?

Monitor for opioid effects. Response 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.

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?

Morphine Meperidine Hydrocodone Response 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 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 hours as needed for pain. The child weighs 30 kg, and the meperidine is available as 50 mg/mL. How many mL, to one decimal place, should the nurse administer per dose?

NOT SURE

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?

Put side rails up and place bed in low position. Response 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?

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

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?

The client had a myocardial infarction 18 months ago Response 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.

What client characteristic may contraindicate the use of tramadol for the treatment of a client's pain following traumatic injuries?

The client has a history of crack cocaine addiction Response 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.

The nurse administers hydromorphone IV to the postoperative client as prescribed. How should the nurse best evaluate the client's response to the medication?

Use a pain assessment tool before and 30 minutes after administration Response Feedback:A standard pain assessment tool should be used both pre- and postanalgesia. This type of quantitative data is 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 client with a history of migraines has been prescribed sumatriptan and is experiencing relief. What physiologic response is the client most likely experiencing?

Vasoconstriction of cranial blood vessels Response 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 hospital client's pain is rated at 9/10, and the nurse is preparing to administer 4 mg hydromorphone PO as prescribed. Before administering the medication, the nurse should:

assess the client's baseline respiratory rate. Response 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.

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?

blood pressure Response 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 in vision.

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?

drowsiness Response 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.

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?

• Tachycardia • Hypertension • Vomiting Explanation: 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.