PREPU UNFINISHED: Chapter 15: Opioid Analgesics

15 of 20 A client with a viral respiratory infection has an intense headache and cough. What drug will best address both of this client's symptoms? • Hydromorphone • Codeine • Ibuprofen • Acetaminophen

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

18 of 20 A terminally ill client has developed increased respiratory secretions and labored breathing. Which medication is prescribed to decrease these symptoms? • meclizine • naloxone • morphine sulfate • ampicillin

• morphine sulfate Explanation: Morphine is used for the treatment of acute pulmonary edema that is responsible for labored breathing and increased respiratory secretions. Meclizine is given for dizziness. Ampicillin is used to treat infection. Naloxone is the opioid antidote.

3 of 5 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? • Heart rhythm • Visual acuity • Blood pressure • Coordination

• Blood pressure Explanation: 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.

1 of 10 How do opioid analgesics relieve moderate-to-severe pain? • increasing the production of endorphins in the brain • inhibiting the transmission of pain signals from the hypothalamus to the spinal cord • inhibiting the transmission of pain signals from peripheral tissues to the brain • preventing the opioid from binding with a receptor site

• inhibiting the transmission of pain signals from peripheral tissues to the brain Explanation: Opioids relieve pain by binding to opioid receptors in the brain, spinal cord, and peripheral tissues. Opioids inhibit the transmission of pain signals from peripheral tissues to the brain, reducing the perception of pain sensation in the brain, producing sedation, and decreasing the emotional upsets often associated with pain. They do not inhibit signals from the hypothalamus. Nor do they increase endorphin production.

1 of 20 A group of nursing students are reviewing information about opioid analgesics. The students demonstrate understanding of the information when they identify which as the gold standard in pain management? • hydromorphone • codeine • oxymorphone • morphine sulfate

• morphine sulfate Explanation: Morphine sulfate is considered the gold standard in pain management and is considered the prototype opioid. All other opioids are measured against this standard. Codeine is also a natural opiate much like morphine but is used to treat moderate pain. Hydromorphone and oxymorphone are derived from morphine and treated chemically and thus are synthetic opioids.

3 of 10 A client with severe diarrhea is receiving opioid therapy. The nurse would be alert for the development of which adverse effect? Select all that apply. • tachycardia • bradycardia • palpitations • tachypnea • mydriasis

• tachycardia • bradycardia • palpitations Explanation: The nurse should monitor for tachycardia, bradycardia, and palpitations as adverse reactions of the cardiovascular system in the client. Miosis, not mydriasis, and decreased respiratory rate are also adverse reactions of opioid analgesics.

14 of 20 A client's healthcare provider has prescribed meperidine 75 mg PO q4h PRN for the client's chronic pain. What education should the nurse provide to this client reagarding this medication? • "Avoid drinking alcohol while taking meperidine." • "Eat small, frequent meals to reduce gastrointestinal upset." • "Avoid sun exposure, or apply high-SPF sunscreen." • "Have blood levels drawn in one week."

• "Avoid drinking alcohol while taking meperidine." Explanation: Drinking alcohol during narcotic treatment can exacerbate CNS depression. Narcotics do not necessitate monitoring of serum levels and they do not cause photosensitivity. Most clients do not experience significant dyspepsia; constipation is by far the most common GI effect.

13 of 20 The nurse is educating a client on the appropriate use of a transdermal patch. Which statements indicate the client is in need of additional education? Select all that apply. • "I should apply the patch to the same spot every time I change it." • "When applying the patch, I should apply pressure for 10 to 20 seconds." • "When I'm wearing the patch, it's okay if I take a hot bath or sit in a sauna." • "I can apply a new patch before I remove the old one." • "I should wash the site where I am applying the patch with soap and hot water."

• "I can apply a new patch before I remove the old one." • "I should wash the site where I am applying the patch with soap and hot water." • "When I'm wearing the patch, it's okay if I take a hot bath or sit in a sauna." • "I should apply the patch to the same spot every time I change it." Explanation: When applying a new transdermal patch, clients should do the following: the site should be cleansed with water only; the old patch should be removed prior to applying the new patch; pressure should be applied to the new patch for 10-20 seconds. Clients should be cautioned against the use of heating blankets/pads over the patch and should be made aware of other heat sources (e.g., hot baths, saunas, and tanning lamps/beds).

11 of 20 The nurse is teaching a client about medications that cause numbness and/or a stupor-like state, are addictive and/or abused, and/or are obtained illegally. Which statements indicates the client understands what the nurse has instructed? • "When I take pain medication prescribed for someone else, I am taking a narcotic." • "When I am given an opioid analgesic for pain, I am actually taking an anesthetic." • "The doctor has given me a prescription for a narcotic." • "When I take pain medication prescribed for someone else, I am taking an anesthetic."

• "When I take pain medication prescribed for someone else, I am taking a narcotic." Explanation: Pain medication obtained illegally (i.e., without a prescription) is considered a narcotic. Anesthetics are medications used to cause a reversible loss of sensation. Opioid analgesics are given and/or prescribed by healthcare professionals for pain management.

4 of 20 When should the nurse obtain the client's blood pressure, pulse, respiratory rate and pain rating after IM administration of an opioid analgesic? • 45 to 60 minutes • 10 to 20 minutes • 30 to 45 minutes • 20 to 30 minutes

• 20 to 30 minutes Explanation: The nurse obtains the client's blood pressure, pulse, respiratory rate and pain rating 20 to 30 minutes after IM administration of an opioid analgesic.

1 of 5 A nurse is caring for a client with renal impairment. The client has been prescribed an opioid analgesic. Which nursing intervention would be most appropriate? • Provide aggressive bowel program. • Administer the drug through the IV route. • Administer an antacid with the drug. • Consult with the prescriber about lowering the dosage of the drug.

• Consult with the prescriber about lowering the dosage of the drug. Explanation: The nurse should lower the dosage of the drug when caring for a client with renal impairment who has been prescribed an opioid analgesic, but only after consulting with the prescriber and obtaining a prescription to do so. The nurse has to provide an aggressive bowel program to clients who experience an adverse reaction on their GI system due to the action of the opioid analgesics. Use of an antacid is recommended only if prescribed by the primary health care provider under specific circumstances. The nurse need not administer the drug through the IV route for a client with renal impairment who has been prescribed opioid analgesics.

10 of 20 Nate is a 24-year-old man, status post--motor vehicle accident, with multiple broken bones including two rib fractures. The physician prescribes a morphine PCA pump for the client's pain. When the nurse assesses Nate, the nurse finds clear breath sounds bilaterally, a respiratory rate of 18, and a weak cough. What would be the priority nursing diagnosis based on this assessment? • Alteration in mobility due to trauma • Alteration in comfort: Pain • Ineffective airway clearance secondary to cough suppression by the drug • Ineffective breathing pattern, hyperventilation

• Ineffective airway clearance secondary to cough suppression by the drug Explanation: The most appropriate diagnosis based on the assessment is ineffective airway clearance secondary to the client's weak cough. The client does have pain and altered mobility, but the priority nursing diagnosis is ineffective airway clearance.

16 of 20 The nurse is caring for a newborn client. The mother was taking opioid analgesics for chronic pain management throughout her pregnancy. Which finding indicates that the infant may be experiencing withdrawal? • Sneezing • Constipation • Bradypnea • Lethargy

• Sneezing Explanation: Within the first few days of life, withdrawal symptoms in the newborn will appear as irritability, excessive crying, yawning, sneezing, increased respiratory rate (tachypnea), tremors, fever, vomiting, and diarrhea.

8 of 20 An 80-year-old man has been prescribed oxycodone for severe, noncancer, chronic pain. He tells the nurse that he has difficulty swallowing and asks if he can crush the tablet before swallowing. The nurse will advise the client that: • crushing the tablet increases the drug's efficacy. • crushing the tablet is a safe option. • there is risk of an extremely high dose available all at once if the tablet is crushed. • the tablet would have no effect if crushed and ingested.

• there is risk of an extremely high dose available all at once if the tablet is crushed. Explanation: The nurse should caution the client against crushing the tablet before ingesting it. Crushing allows an extremely high dose of the drug to be available all at once, instead of being released slowly over time. Severe adverse effects are possible when it is used in this manner.

5 of 5 How will a client's impaired renal function affect the pharmacokinetics of morphine? • Onset of desired effect will be shortened. • Duration of action will be prolonged. • Desired effect will be lessened. • The peak drug effect will occur earlier.

• Duration of action will be prolonged. Explanation: Clients with renal impairment should take minimal doses of morphine for the shortest effective time because usual doses may produce profound sedation and a prolonged duration of action. Neither desired effect, onset, nor peak are the concerns.

9 of 20 A postsurgical client has been provided with a morphine patient-controlled analgesic (PCA) but has expressed reluctance to use it for fear of becoming addicted. How can the nurse bestrespond to this client's concerns? • "You don't need to worry. It's actually not true that you can get addicted to the medications we use in a hospital setting." • "It is not uncommon to develop a dependence on pain medications, but this usually takes place over a long period and is not the same as addiction." • "If you do become addicted, we'll make sure to provide you with the support and resources necessary to help you with your recovery." • "It's important that you accept that your current need to control your pain is more important than fears of becoming addicted."

• "It is not uncommon to develop a dependence on pain medications, but this usually takes place over a long period and is not the same as addiction." Explanation: Addiction to opioids is a rare occurrence among hospital clients who do not have a history of drug abuse. It would be inappropriate to downplay the client's concerns, however. A more appropriate response would be to explain the phenomenon of dependence and to differentiate it from addiction.

15 of 20 Which statement by the nurse indicates the need for follow-up education regarding the relationship between acute pain management and physical dependence? • "Maintaining good pain control is crucial in alleviating the appearance of dependence." • "To prevent returning to dependence behaviors, clients with a history of psychological dependence experience pain and need to be provided with adequate pain relief in a timely manner." • "Delays in medication administration can cause my client to ask repeatedly for pain medication, which can be misinterpreted as 'drug-seeking' behavior." • "Once a client has experienced dependence (psychological or physical), he or she will continue the drug-seeking behavior regardless of whether or not they are really experiencing pain when receiving opioid analgesics for pain control on an acute or short-term basis."

• "Once a client has experienced dependence (psychological or physical), he or she will continue the drug-seeking behavior regardless of whether or not they are really experiencing pain when receiving opioid analgesics for pain control on an acute or short-term basis." Explanation: It is typically the behavior of the nurse and/or health care professional in delaying medication administration that leads clients to manifest behaviors that can be misinterpreted as "drug-seeking." Regardless of a client's past history (i.e., physical or psychological dependence), the client's perceived pain requires medical intervention in a timely manner. Opioid analgesics administered over the short term for acute pain do not produce physical dependence.

2 of 20 A woman who is breastfeeding her newborn is prescribed an opioid analgesic for treatment of pain related to her cesarean birth. The nurse administers the analgesic at 11:00. The earliest that the nurse should allow the mother to breastfeed her newborn would be at which time? • 12:00 • 13:00 • 15:00 • 14:00

• 15:00 Explanation: A lactating female should wait at least 4 to 6 hours after taking an opioid analgesic to breastfeed the infant. Therefore, the earliest time would be at 15:00. In less than 4 to 6 hours, the opioid analgesic can be found in the breastmilk and will have effects on the newborn.

2 of 10 When should the nurse obtain the client's blood pressure, pulse, respiratory rate and pain rating after oral administration of an opioid analgesic? • 10 minutes • 20 minutes • 30 minutes • 15 minutes

• 30 minutes Explanation: The nurse obtains the client's blood pressure, pulse, respiratory rate and pain rating 30 or more minutes after oral administration of an opioid analgesic.

8 of 20 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 • Contact the care provider to question the dose • Contact the care provider to question the frequency of administration • Contact the care provider to question concurrent use of an NSAID and codeine

• Administer the medication as prescribed and monitor the client's pain Explanation: The correct dosage for codeine administered for pain by mouth is 15-60 mg q 4 - 6 h. The other options are incorrect oral dosages.

16 of 20 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 non-opioid medication he is receiving. What should the nurse suspect is causing this client's pain? • Administer a higher dose of morphine, as prescribed • Assess the client for further signs of withdrawal syndrome. • Monitor the client for hypersensitivity. • Assess the client for further signs of addiction

• Assess the client for further signs of withdrawal syndrome. Explanation: 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.

6 of 10 When reviewing information about medications that are compounded by the pharmacist, the nurse knows which statements are true? Select all that apply. • Brompton's mixture is the most commonly used solution. • It is necessary to monitor for adverse reactions of each drug contained in the preparation. • It is appropriate for the client and/or caregiver to formulate their own compounding medication from supplies they have on hand. • A clinical pharmacist will prepare the medication in a form (e.g., solution, salve, or suppository) best suited for the individual client. • The time interval for administration is the same for all compounding medications, regardless of the drugs comprising the solution, salve, or suppository.

• Brompton's mixture is the most commonly used solution. • A clinical pharmacist will prepare the medication in a form (e.g., solution, salve, or suppository) best suited for the individual client. • It is necessary to monitor for adverse reactions of each drug contained in the preparation. Explanation: Brompton's mixture is the most commonly used solution. It is necessary to monitor for adverse reactions of each drug contained in the preparation. The time interval for administration will be different, based upon the individual drugs that make up the solution, salve, or suppository. A clinical pharmacist (not the client or caregiver) will prepare the compounding medication in a form best suited for the individual client.

6 of 20 When providing care to a client receiving an opioid analgesic, which would be most important for the nurse to do if the client's respiratory rate drops? • Encourage the client to take deep breaths. • Instantly administer methadone. • Monitor the client for signs of nausea and vomiting. • Position the client in Fowler position.

• Encourage the client to take deep breaths. Explanation: When caring for a client with a drop in the respiratory rate, the nurse should coach the client to breathe to increase the respiratory rate. Naloxone may be administered if absolutely needed, but only after consultation with the primary health care provider and only very cautiously by the nurse. Naloxone removes all of the pain-relieving effects of the opioid and may lead to withdrawal symptoms or the return of intense pain. The nurse should not administer methadone in case of a drop in respiratory rate. The nurse need not position the client in a Fowler position. Nausea and vomiting are not known to occur when the respiratory rate drops.

3 of 20 A nursing instructor is preparing a teaching plan for a nursing class on opioid analgesics. Which body system would the nursing instructor describe as not adapting to and compensating for the secondary effects of this class of drugs? • nervous system • respiratory system • cardiovascular system • GI system

• GI system Explanation: The one body system that does not adapt and compensate for the secondary effects of opioids is the GI system. Slow motility and constipation are seen with all opioid use. The respiratory system shows depressed respiratory rate and rhythm. The cardiovascular system can have tachycardia, bradycardia, palpitations, peripheral circulatory collapse, and facial flushing. The central nervous system is where the opioid binds causing a sense of euphoria, weakness, headache, sedation, agitation, tremor, increased intracranial pressure to name a few.

19 of 20 What action should the nurse take when administering meperidine 75 mg IM every 4 hours to a young adult? • Call the health care provider for a smaller dose. • Give the dose by mouth. • Administer half the dose. • Give the medication as prescribed.

• Give the medication as prescribed. Explanation: The client should be administered the full dose of medication, which is within dosing recommendations. A client with adequate hepatic and renal function should not receive a lower dose of meperidine without specific instruction from the prescribing care provider. There is no apparent reason to change the route of administration, and such action cannot be implemented without the instruction of the prescribing care provider.

3 of 20 The nurse is explaining to a client about the analgesic and its possible adverse effects. The client is receiving an opioid analgesic. What would be important to teach this client is a possible adverse effect of this drug? • Hypotension • Dysrhythmias • Ataxia • Blurred vision

• Hypotension Explanation: Orthostatic hypotension is commonly seen with some narcotics. Ataxia, blurred vision, and dysrhythmias are not generally adverse effects of an opioid analgesic.

4 of 20 The nurse is caring for a client taking Talwin. What would be an appropriate nursing diagnosis for this client's care plan? • Disturbed kinesthetic perception related to CVS effects • Impaired gas exchange related to respiratory depression • Diarrhea related to GI effects • Powerlessness due to low dosage

• Impaired gas exchange related to respiratory depression Explanation: The correct nursing diagnosis includes impaired gas exchange related to respiratory depression. Appropriate nursing diagnosis does not include diarrhea or disturbed perception related to CVS effects.

5 of 10 The World Health Organization's (WHO) pain-relief ladder includes which components? Select all that apply. • All steps of the ladder incorporate the utilization of both an opioid and non-opioid analgesic for pain treatment. • The goal of treatment is freedom from pain. • All steps of the ladder may incorporate use of an adjuvant. • Each step of the ladder is based upon the intensity of the perceived pain. • It consists of three steps.

• It consists of three steps. • Each step of the ladder is based upon the intensity of the perceived pain. • The goal of treatment is freedom from pain. • All steps of the ladder may incorporate use of an adjuvant. Explanation: The goal of the World Health Organization's (WHO) three-step ladder is freedom from pain and is based upon perceived pain intensity. Step 1 of the ladder uses only a non-opioid analgesic with or without the addition of an adjuvant. Steps 2 and 3 indicate the potential to incorporate use of both an opioid and non-opioid analgesic as well as an adjuvant.

10 of 20 Which should be included when assessing pain? (Select all that apply.) • What medications client usually takes to relieve the pain • What factors cause the pain to improve or worsen • Location of the pain • Intensity of pain

• Location of the pain • Intensity of pain • What factors cause the pain to improve or worsen • What medications client usually takes to relieve the pain Explanation: Nursing assessment of a client's pain should include a description of the pain, location, intensity, severity and duration, factors that influence pain, and how the client has previously treated the pain.

17 of 20 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 withdrawal syndrome. • Monitor for opioid effects. • Administer naloxone. • Assess for congenital anomaly.

• Monitor for opioid effects. Explanation: 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.

20 of 20 What reaction should the nurse assess for when a client is prescribed a nonopioid analgesic in addition to a narcotic analgesic? • antagonism • additive effect • interference • increased exertion

• additive effect Explanation: Acetaminophen is added to narcotic analgesics for additive effects of pain relief without the addition of narcotic adverse effects. Acetaminophen will provide an antagonistic effect nor cause an interference of action. Acetaminophen will increase excretion.

10 of 10 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. • Monitor the client's temperature before and after administration • Avoid administering any other medications while the transdermal patch is in place • Monitor the client's respiratory status closely • Ensure the client has access to the call light • Keep the client's bed in the lowest position

• Monitor the client's respiratory status closely • Keep the client's bed in the lowest position • Ensure the client has access to the call light Explanation: 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.

12 of 20 In the healthcare setting, the nurse knows that which opoid analgesic drugs are used? Select all that apply. • Methadone • Heroin • Codeine • Morphine • Meperidine

• Morphine • Meperidine • Methadone • Codeine Explanation: Heroin is considered a narcotic substance and is never used in the healthcare setting. Morphine, meperidine, methadone, and codeine are all opioid agonists used in the healthcare setting.

2 of 5 A client is in the end of life and has developed increased respiratory secretions and labored breathing. The health care provider will order which medication to decrease these symptoms? • Ampicillin • Morphine sulfate • Meclizine (Antivert) • Azithromycin

• Morphine sulfate Explanation: Morphine is used for the treatment of acute pulmonary edema. Meclizine (Antivert) is given for dizziness. Ampicillin is used to treat infection, as is azithromycin.

1 of 20 A client who lives with chronic pain has just learned that she is pregnant. What narcotic analgesic is most appropriate for this client? • Oxycodone • Propoxyphene • Fentanyl • Sufentanil

• Oxycodone Explanation: Oxycodone is classified as a pregnancy category B drug. Fentanyl is classified as a pregnancy category C drug. Propoxyphene is classified as a pregnancy category C drug. Sufentanil is classified as a pregnancy category C drug.

6 of 20 A client has been ordered a fentanyl patch for chronic pain. What client teaching should be provided to the client and family upon discharge? • Remove it daily and clean skin. • Apply it to the chest only. • Apply it for breakthrough pain. • Remove the patch every 3 days.

• Remove the patch every 3 days. Explanation: A fentanyl patch has a slow onset of action, but duration lasts about 72 hours making a new application necessary every 3 days. The patch can and should be applied to other areas of the skin, not solely on the chest with skin cleaning done prior to each new application. Fentanyl is not effective for breakthrough pain.

11 of 20 The client has been diagnosed with a mild sprain in his left ankle. He has been taking acetaminophen and is currently rating his pain as 2-3 on a 0-10 scale ("0" indicating no pain). According to the World Health Organization's (WHO) analgesic protocol, what level (step) of pain control is the client demonstrating? • Step 4 • Step 2 • Step 3 • Step 1

• Step 1 Explanation: The client is at Step 1. There is a diagnosis of a mild injury, and the client is experiencing relief from a non-opioid analgesic as evidenced by the rating of 2-3 on a 0-10 scale. Step 2 is intended for mild to moderate pain, or persistent/increasing pain, which is not indicated. Step 3 is intended for moderate to severe pain, or persistent/increasing pain, which is not indicated. This pain protocol has only three steps.

13 of 20 The nurse is reviewing the discharge instructions with the client going home on an opioid analgesic for pain management. What would the nurse include in the instructions? Select all that apply. • Keep a record of bowel movements. • Keep the room well lit during the day. • Limit fluid intake. • Rise slowly from a sitting or lying position. • Take a laxative/stool softener.

• Take a laxative/stool softener. • Keep the room well lit during the day. • Rise slowly from a sitting or lying position. • Keep a record of bowel movements. Explanation: Constipation is an issue in clients receiving opioid analgesics, therefore taking a laxative/stool softener may be necessary, as well as increasing fluid intake and keeping a record of bowel movements. A drop in blood pressure (orthostatic hypotension) would require care in rising from a sitting or lying position. Miosis (pinpoint pupils) decreases the ability to see in dim light.

17 of 20 What client characteristic may contraindicate the use of tramadol (Ultram) for the treatment of a client's pain following traumatic injuries? • The client has a history of crack cocaine addiction • The client required a transfusion of packed red blood cells on admission • The client has developed a wound infection and is at risk of sepsis • The client is 48 hours post-orthopedic surgery

• The client has a history of crack cocaine addiction Explanation: 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.

12 of 20 Of the following clients, which one will be most likely to develop physical dependence upon the opioid analgesic they are receiving for pain management? • The client recovering from cholecystectomy • The client recovering from an ankle fracture • The client living with a chronic noncancer-related illness • The client recovering from a below-knee amputation

• The client living with a chronic noncancer-related illness Explanation: The client living with a chronic, noncancer-related illness will be the one receiving the highest dose in the most frequent time interval; this client is considered chronically ill. The clients recovering from surgical procedures (cholecystectomy and below-knee amputation) as well as an ankle fracture are receiving opioid analgesics for acute pain, and will be healed before physical dependence develops.

7 of 10 The client is receiving opiod analgesics for pain management. What is the best time to perform therapeutic activities such as encouraging ambulation and practicing cough/deep breathing exercises with this client? • Within 30 minutes of administration • Within two to three hours after administration • Within one to two hours after administration • Within one hour of administration

• Within one to two hours after administration Explanation: The best time to perform therapeutic activities such as encouraging ambulation and/or deep breathing exercises is typically within one to two hours after administration of an opioid analgesic. This is when the drug is producing its greatest analgesic effect.

18 of 20 A postsurgical client has been prescribed morphine to address the pain that is anticipated over the next 24 to 48 hours. What is the most effective strategy to manage a client's postsurgical pain for the initial 24 to 48 hours? • encouraging the client to endure the pain as much as possible before administering morphine • administering morphine every 4 hours, with gradually decreasing doses over the next several days • administering morphine on a scheduled basis and supplementing it with additional morphine when the pain worsens • administering the maximum safe dose of morphine for 12 to 24 hours and then transitioning to nonsteroidal anti-inflammatory drugs (NSAIDs)

• administering morphine on a scheduled basis and supplementing it with additional morphine when the pain worsens Explanation: In general, morphine should be given continuously or on a regular schedule of intermittent doses, with supplemental or bolus doses when needed for breakthrough pain. None of the other options provide accurate information about the management of postsurgical pain.

5 of 20 The nurse should question the health care provider's IV morphine prescription for which client? • a 45-year-old female, 1-day postoperative mastectomy • a 17-year-old female, 1-day postoperative appendectomy • an 8-year-old male with a compound fractured femur • an 88-year-old female with failure to thrive

• an 88-year-old female with failure to thrive Explanation: Opioid analgesics should be used cautiously in older adults, especially if they are debilitated. Treatment with morphine 1 day after either a mastectomy or an appendectomy is appropriate for pain management. The treatment of pain with morphine is appropriate for a client with a compound fractured femur.

9 of 10 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: • ensure that there is naloxone available at the bedside. • assess the client's apical heart rate for one minute. • ensure the client is aware of NSAID alternatives to this narcotic. • assess the client's baseline respiratory rate.

• assess the client's baseline respiratory rate. Explanation: 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 one-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.

4 of 5 A nurse is teaching a client about her prescription for acetaminophen that she will take at home. This medication consists of acetaminophen and what other likely drug that enhances the analgesic effect of acetaminophen? • tramadol • codeine • methadone • acetylsalicylic acid

• codeine Explanation: Codeine is often given with acetaminophen for additive analgesic effects. None of the other medications are used in combination with acetaminophen.

8 of 10 The nurse administered a scheduled dose of hydromorphone to a client.30 mintues ago. It is now time to do her follow-up assessment. The nurse should anticipate which findings on her follow-up assessment? Select all that apply. • Increase in temperature • slight decrease in respiratory rate • decrease in pain rating • disorientation to person, place and time • decrease in oxygen saturation

• decrease in pain rating • slight decrease in respiratory rate Explanation: Narcotics such as hydromorphone should reduce the client's pain and a certain degree of respiratory depression nearly always occurs. However, this should not affect the client's oxygen saturation level. Temperature is not normally affected. Drowsiness is very common, but the client would not be expected to become disoriented.

20 of 20 A group of nursing students are reviewing information about the different classifications of opioids. The students demonstrate understanding of the information when they identify which as an opioid agonist? Select all that apply. • buprenorphine • fentanyl • hydromorphone • pentazocine • oxycodone

• hydromorphone • fentanyl • oxycodone Explanation: Hydromorphone, fentanyl, and oxycodone are opioid agonists. Buprenorphine and pentazocine are agonist-antagonists.

19 of 20 A client has been admitted to the emergency department after overdosing on oxycodone. What nursing diagnosis should the nurse prioritize? • ineffective role performance • impaired swallowing • impaired gas exchange • ineffective airway clearance

• impaired gas exchange Explanation: The decreased respiratory rate that accompanies opioid overdoses causes impaired gas exchange. This is a priority over considerations such as swallowing and role performance. The airway is not occluded, so ineffective airway clearance is not a priority.

14 of 20 Following the subcutaneous (subcut) administration of pain medication, the nurse would know to check the client's vital signs in what amount of time? • in 10 to 20 minutes • in 30 or more minutes • in 20 to 30 minutes • in 5 to 10 minutes

• in 20 to 30 minutes Explanation: Vital signs should be taken within 20 to 30 minutes after intramuscular (IM) or subcutaneous (subcut) medication administration. Vital signs should be taken within 5 to 10 minutes following intravenous (IV) administration, and 30 or more minutes following oral administration.

7 of 20 A nurse has just administered an IM injection of meperidine (Demerol) to an elderly client. The priority nursing action for the nurse would be which? • make sure the side rails are up. • check the temperature of the room. • close the draperies. • make sure the client is positioned comfortably.

• make sure the side rails are up. Explanation: The priority nursing action will be to make sure that the side rails are up. Meperidine can cause dizziness and sedation, which increase the risk of the client falling. The side rails should be up to remind the client that she should not get out of bed without help. Closing the draperies, checking the temperature of the room, and making sure the client is comfortable creates an environment that will enhance the efficacy of the medication therapy but are not the priority actions.

5 of 20 A client is receiving opioid therapy. The nurse should be alert to the possibility that which could occur if the client receives an opioid agonist-antagonist? • respiratory depression • increased risk for CNS depression • hypotension • opioid withdrawal symptoms

• opioid withdrawal symptoms Explanation: The nurse should know that the interaction of opioid analgesics with an opioid agonist-antagonist will lead to opioid withdrawal symptoms in clients. Increased risk for CNS depression occurs when opioid analgesics interact with antihistamines, antidepressants, sedatives, and phenothiazines. Respiratory depression and hypotension occur when opioid analgesics interact with barbiturates.

9 of 20 A nurse is caring for a 49-year-old client in the intensive care unit. The client was in a motor vehicle accident and is in severe pain. The client has been given morphine. After 2 days in the unit, the nurse can detect nasal congestion when the client speaks to her. The nurse will monitor for which? • pneumonia. • myocardial infarction. • hypersensitivity to the drug. • renal impairment.

• pneumonia. Explanation: Respiratory depression is a common adverse effect of morphine. If the client gets a cold, as the nasal congestion can be a sign, this respiratory depression could cause retained secretions and put the client at greater risk for developing pneumonia. The drug does not cause myocardial infarction or renal impairment. A common cold is not known to cause hypersensitivity to the morphine.

2 of 20 A client has received a narcotic agonist for pain relief. The nurse should monitor the client for what? • tachypnea. • pupil constriction. • hypertension. • diarrhea.

• pupil constriction. Explanation: Narcotics are associated with pupil constriction, constipation, orthostatic hypotension, and respiratory depression with apnea.