PNE 104 Ch 16. Opioid Antagonist. Clinical Pharm. Susan Ford 11th Ed.

The health care provider has ordered 0.2 mg naloxone to be administered intramuscularly stat. The pharmacy has available naloxone 0.4 mg/mL. How many mL will the nurse administer to the client?

0.5 Rationale: If there is 0.4 mg in 1 mL and the nurse wishes to give 0.2 mg, then the nurse should withdraw 1/2 of 1 mL or 0.5 mL.

When describing the onset of action of naloxone, the nurse would explain that the drug achieves its effect in which amount of time?

1 to 2 minutes Rationale: Naloxone is capable of restoring respiratory function within 1 to 2 minutes of administration. The shorter the time to restoring respiration the less time the client has to depend on manual or mechanical ventilation and the better the outcome for the client.

Nursing Diagnoses:

1. Impaired spontaneous ventilation 2. Acute pain

Uses for opioid antagonists:

1. Post op respiratory depression 2. opioid adverse effects 3. overdose

Adverse reactions to opioid antagonists:

1. nausea 2. vomiting 3. sweating 4. tachycardia 5. increased BP 6. tremors

Action for opioids antagonists:

1. prevents/reverses the effects of opioid drugs. 2. The antagonists reverses the opioid effects by competing for the opiate receptor sites/displacing the opioid drug.

Naloxone 2 mg IM has been ordered for a post surgical client. The pharmacy has sent to the floor naloxone 1 mg/mL. How much naloxone will the client receive?

2 Rationale: The nurse is to administer 2 mg of naloxone. The pharmacy has supplied 1 mg/1 mL. Therefore, in order to administer 2 mg, the nurse must administer 2 mL.

Several people have recently undergone abdominal surgery, and each client will receive morphine sulfate for postoperative pain. Which client is at the greatest risk for respiratory depression as a result of taking morphine sulfate?

A 37-year-old client with no history of drug or opioid use. Rationale: The opioid-naive client is at the greatest risk for respiratory depression as a result of taking an opioid like morphine sulfate.

A nursing student demonstrates an understanding of the actions of opioid antagonists when making which statement?

A client who receives an opioid antagonist will also experience a reversal of pain relief. Rationale: An opioid antagonist is not selective for specific adverse reactions. When an antagonist is given for respiratory depression, it is important to remember that the antagonist reverses all effects. Therefore, a client who receives an antagonist to reverse respiratory effects will also experience a reversal of pain relief-that is, the pain will return. If the individual has not taken or received an opioid, an antagonist has no drug effect.

Which of the following clients is more likely to have respiratory depression when receiving an opioid medication, requiring administration of an opioid antagonist?

A surgical client who is not used to taking opioid analgesics. Rationale: A surgical client who is not used to taking opioid analgesics on an continual basis is opioid naive and is most likely to have respiratory depression. Those who use opioid analgesics more often tend to have fewer side effects, such as respiratory depression.

A client's family asks why the nurse has placed suction equipment in the room immediately after administering a dose of naloxone. Which explanation by the nurse is correct?

Abrupt reversal of opioid-induced respiratory depression may cause vomiting. Rationale: It is important to keep suction equipment readily available because abrupt reversal of opioid-induced respiratory depression may cause vomiting. None of the other rationales provided is a valid reason for adding suction equipment to the room of a client who requires a dose of naloxone.

Chapter 16 Review: Prepare for NCLEX: Alternate-Format-Questions #4 In the recovery room, the physician prescribes naloxone 0.4mg by injection as the initial dose for opioid-induced respiratory depression; it may be followed in 5 minutes with 0.2mg. Orders read that the nurse should contact the primary health care provider when a total of 1mg is given. How many times can the nurse give the drug before contacting the PCP?

Answer: 0.4mg+0.2mg+0.2mg+0.2mg

Chapter 16 Review: Prepare for NCLEX: Build your knowledge #1 Which drug would most likely be prescribed for treatment of a client who is experiencing an opioid?

Answer: 2 - Naloxone

Chapter 16 Review: Prepare for NCLEX: Build your knowledge #5 Select the drugs that should be monitored for possible respiratory depression? Select all that apply. 1. Celebrex 2. Dilaudid 3. Meperidine 4. Tylenol

Answer: 2, 3, 2. Dilaudid 2mg 3. meperidine 50mg

Chapter 16 Review: Prepare for NCLEX: Build your knowledge #2 What is the action when an opioid antagonist is administered?

Answer: Displaces the opioid drug from the receptor site

Chapter 16 Review: Prepare for NCLEX: Apply your knowledge #3 When client, given an opioid analgesic for acute pain, should the nurse monitor most closely for respiratory distress?

Answer: Man who has never used an opioid pain medication

The nurse is caring for a postoperative client taking an opioid medication for pain. The nurse assesses the client to have bradypnea and an oxygen saturation value of 90%. Which actions should the nurse perform before administering the ordered opioid antagonist?

Assess the client's other vital signs. Rationale: Blood pressure, pulse, and respirations are important assessments to make prior to administering an opioid antagonist. It is unnecessary to call for a respiratory therapy consult because the cause of the respiratory depression is known. While assessing and managing pain are important postoperative interventions, the respiratory depression-management interventions are the most important ones to be addressed.

A 39-year-old opioid-naive client has received morphine sulfate 5 mg IV. Ten minutes later, the nurse notices the client is sleepy and drowsy. What should the nurse do first?

Assess the client's vital signs. Rationale: The first step in the nursing process is to assess. Therefore, the first thing the nurse should do in this instance is assess the client's vital signs, especially the respiratory rate.

After administration of an opioid antagonist, the nurse should perform which action?

Assess vital signs every five minutes until the client responds. Rationale: The client's vital signs should be assessed every five minutes until the client responds to the antagonist, and then every five to 15 minutes once they have responded. Once per hour is too long for vital signs and oxygen saturation assessment. While pain is an important nursing assessment, it is less critical than vital signs after respiratory depression has occurred.

The nurse is caring for a postoperative client receiving an opioid medication for pain management. The nurse finds the client lethargic with a respiratory rate of 6 breaths per minute. Which of the following actions should be performed first?

Attempt to arouse the client and coach his or her breathing pattern. Rationale: Sometimes the somnolence and pain relief produced by the opioid drug will slow the client's breathing pattern. This can be alarming if the respiratory rate the nurse has been monitoring has been rapid because of anxiety and pain. The first step is to make efforts to arouse the client and coach his or her breathing pattern, if possible. It would be important to administer an opioid antagonist as well. A code is not required at this time but action is required above simply monitoring the client's pain level.

A nurse has administered 2 mg butorphanol (Stadol) to a female client for postoperative pain. Five minutes after administration of the medication, the client's respiratory rate has decreased dramatically and she is sleeping. What should the nurse do first?

Attempt to rouse the client. Rationale: If the nurse suspects respiratory depression after the administration of an opioid, the best thing to do first is to attempt to rouse the client. The respiratory rate may decrease dramatically as the client shifts from anxiety related to pain to pain relief.

The nurse has administered a dose of naloxone and the client's respiratory depression improved within five minutes. When the nurse reassessed the client two hours later, the client demonstrates symptoms of respiratory depression. Which action should the nurse perform next?

Call the provider as another dose of opioid antagonist may be necessary. Rationale: The effects of some opioids may last longer than the effects of naloxone. A repeat dose of naloxone may be ordered if results obtained from the initial dose are unsatisfactory. Therefore, calling for an order would be an appropriate response. Taking no action in light of respiratory depression, or merely continuing to monitor the client, could lead to deterioration in the client's condition. No medication should be administered without a provider order.

A nursing student indicates a need for further instruction on opioid antagonists when making which statement?

Clients who do not take opioids frequently have more tolerance for them. Rationale: Patients involved in long-term opioid therapy for pain build tolerance to the physical adverse effects. It is the patient who does not use opioids routinely and who is being given an opioid drug for acute pain relief or a surgical procedure who is at most risk for respiratory depression.

A client who is receiving an opioid develops a slowed breathing pattern due to the drug's effect of somnolence and pain relief. When providing care to this client, which would be most important for the nurse to do?

Coach the client to breathe. Rationale: Sometimes the somnolence and pain relief produced by the opioid drug will slow the client's breathing pattern. The nurse should make efforts to arouse the client and coach him or her to breathe. The nurse need not monitor the blood pH level of the client, continue administering the prescribed drug, or increase the drug dosage level to be administered when caring for a client with a lowered breathing pattern because these interventions will not help increase the client's breathing rate.

What is the mechanism of action of naloxone (Narcan), an opioid antagonist?

Displaces opioids by more effectively binding to opioid receptor sites. Rationale: An opioid antagonist acts by more effectively binding to opioid receptor sites and thus competing with opioids for activation on a cell.

Naloxone (Narcan) will reverse the effects of which drug?

Fentanyl (Duragesic) Rationale: Naloxone (Narcan) is an opioid antagonist, which means it will only reverse the effects of opioids like fentanyl (Duragesic).

The nurse has learned that when giving Narcan IV to reverse respiratory depression, the drug is given by slow IV push. This is done for which reason?

Giving it fast will cause withdrawal and return of the pain. Rationale: When Narcan is used to reverse respiratory depression, the drug is given IV slowly until the respiratory rate begins to increase. If it is given quickly as a bolus, it will cause withdrawal and the return of intense pain. The drug handbook states to give it slowly, but that is not the rationale behind the action.

Although naloxone is given to counter opioid medication side effects such as respiratory depression, what additional issues (if any) may result from administration of an opioid antagonist?

Increase in the client's pain rating. Rationale: An opioid antagonist will counter not only the negative effects of an opioid medication but the beneficial effects of the opioid (such as pain relief) as well, resulting in an increase in the client's pain rating. It would not result in a decrease or lack of change in the pain rating.

The client is receiving an opioid medication for pain. During an assessment, the nurse notes respiratory depression in the client. Which actions should the nurse perform next? Select all that apply.

Make an effort to arouse the client to change his breathing pattern if possible. Review the medical record for which drug could be causing the symptom. Review the allergy and health histories and current treatment modalities. Rationale: The first action upon noting respiratory depression should be to rouse the client to change his or her breathing pattern. The nurse should also review the medical record to determine which medication is the cause so that an appropriate opioid antagonist can be selected. It is also appropriate to review the initial health history, allergy history, and current treatment modalities. In the case of respiratory depression, an opioid antagonist should be ordered; therefore, taking no action and monitoring the client (or taking no action at all) could lead to worsening of the condition. These options are incorrect.

When giving Narcan to reverse the actions of an opioid, the nurse can give this only how many times?

May be repeated once if the primary care provider orders it. Rationale: The effects of some opioids may last longer than the effects of Narcan. A repeat dose may be ordered by the provider if results obtained from the initial dose are unsatisfactory. The duration and close observation of the patient depend upon the patient's response to the drug.

Which medications are opioids for which naloxone may be given to counter the effects?

Meperidine Rationale: Meperidine is an opioid medication for which naloxone is an opioid antagonist, and for which naloxone counters the effects. Acetaminophen is not an opioid medication and naloxone would have no effect on a client receiving this medication. Ibuprofen and naproxen are nonsteroidal anti-inflammatory drugs, and naloxone would have no effect on a client receiving these medications

The client undergoing surgery begins to have respiratory depression from opioids. The drug of choice for the anesthetist to administer is which?

Narcan Rationale: Narcan is used today as an opioid antagonist and is capable of restoring respiratory function within 1 to 2 minutes after administration. The other drugs are used in anesthesia but are not opioid antagonists.

A client in the PACU is experiencing respiratory depression from opioids given during surgery. The physician orders which dosage of Narcan for the client?

Narcan 0.1-0.2 mg IV at 2-3 minute intervals Rationale: The correct dose for the client is Narcan 0.1-0.2 mg IV at 2-3 minute intervals. The others are medication errors and never would be ordered for a client.

A client who was recently diagnosed with cancer is now receiving morphine for pain. Since this client has been receiving morphine for only a short time, he is best described by which term?

Opiate naive. Rationale: An opiate tolerant client is one who, because of previous opioid use, has developed a drug tolerance. An opioid tolerant client typically requires a larger-than-usual dose for pain relief. Conversely, an opiate naive client has not received sufficient opioids for development of tolerance. The client described in the scenario is opiate naive.

Key points: Opioid naïve

Patients who seldom use opioids pain relivers are termed opioid naïve; they are at the greatest risk of experiencing respiratory depression when administered opioids.

The nurse is to administer an opioid antagonist. The nurse knows that the valid reasons for administering this type of medication include what reasons? (Select all that apply.)

Postoperative acute respiratory depression Suspected or known acute opioid overdosage Adverse effects related to opioid administration Rationale: Opioid antagonists are used for the treatment of acute respiratory depression, overdosage, and adverse effects of opioid administration. Administration often counters the pain-relieving effects of an opioid medication and does not enhance opioid effects. These are not actions of an opioid antagonist.

A client received Duramorph via spinal injection for lower abdominal surgery. The client reports severe pain for which the nurse administers morphine sulfate. Which is the most important to assess immediately after administering morphine sulfate?

Respiratory rate Rationale: Respiratory depression is the most severe adverse effect from opioid overdosing. Temperature, pain scale and urinary output are normal assessments not necessarily related to opioid overdosing.

A nurse is caring for a client who receives an opioid antagonist through the IV route. The client is experiencing acute pain. Which would be most important for the nurse to do when monitoring and managing the client's acute pain?

Review circumstances that led to the use of an opioid antagonist. Rationale: When monitoring or managing acute pain in a client who receives an opioid antagonist, the nurse should review the circumstances that led to the need for the antagonist. When the antagonist is administered through the IV route, the drug should be administered via a slow IV push. A rapid bolus will increase the pain experienced by the client. The nurse need not reduce the drug dose that is administered to the client in case the client experiences pain. Although monitoring blood pressure and pulse is an important assessment, it is not essential because the client's respiratory status was the reason for the antagonist.

Which adverse reactions may occur as a result of administering an opioid antagonist?

Sweating, tachycardia, and increased blood pressure. Rationale: Side effects of opioid antagonists include nausea and vomiting, sweating, increased blood pressure, and tremors. All other side effects listed are not side effects of opioid antagonists.

If a client is given an opioid antagonist without having taken an opioid, what will happen?

The antagonist will have no effect on the client. Rationale: Because an opioid antagonist reverses the effects of an opioid, if the client has not ingested an opioid, it will not have an effect.

A nurse is caring for a client who required an opioid antagonist. Which should the nurse confirm to ensure that administration of the opioid antagonist is not contraindicated in the client?

The client is not hypersensitive to the opioid antagonist. Rationale: The nurse should confirm that the client is not hypersensitive to the opioid antagonist to ensure that its administration is not contraindicated in the client. Elevated blood pressure is an adverse reaction of opioid antagonists, but administration of these drugs is not known to be contraindicated in clients with high blood pressure. Opioid antagonists are used cautiously in clients who are lactating and in clients who have cardiovascular disease, but presence of these conditions does not contraindicate the use of opioid antagonists.

The nurse is caring for a postoperative client with a history of opioid abuse who has been ordered to receive a dose of an opioid antagonist medication. Which issues should the nurse be prepared to address?

The client may begin to demonstrate symptoms of withdrawal. Rationale: The client may begin to demonstrate symptoms of withdrawal when he or she has a history of opioid abuse and is administered an opioid antagonist. The other answers are incorrect. In fact, clients will likely have increased pain due to antagonistic effects of the drug. The standard dosage and a single dose will be administered even with a history of opioid abuse.

The client is experiencing respiratory depression and is administered Narcan per physician's order. Two minutes later, the client shows no signs of improvement; in fact, the respiratory status worsens. The nurse should expect which?

The condition is not due to opioid overdose. Rationale: Narcan is capable of restoring respiratory function within 1-2 minutes after administration. Therefore, if the client does not respond, the respiratory depression must be from another condition and needs to be addressed as quickly as possible.

Nursing Alert - Effects of some opioids p.189

The effects of some opioids may last longer than the effects of naloxone (Narcan). A repeat dose of the naloxone may be ordered if results obtained from the initial dose are unsatisfactory. The duration of close pt. observation depends on the pt's response to the administration of the opioid antagonist.

The client has had an opioid overdose. Prior to the administration of an opioid antagonist the client's vital signs are 100/50, P40, respirations 6, and afebrile temperature. How would the nurse evaluate that the medication has been therapeutic?

The respiratory rate is 8 bpm. Rationale: An increase in the respiratory rate would indicate that the medication was effective. The nurse would also expect the heart rate to increase as well as the blood pressure. The level of consciousness can vary client to client.

Nursing Alert - Naloxone reverse p.189

When naloxone is used to reverse respiratory depression & resulting somnolence, the drug is given by slow IV push until the respiratory rate begins to increase/somnolence abates. Keep in mind that giving a rapid bolus will cause withdrawal/return of intense pain.

The nurse has just administered an opioid antagonist to a client who had been experiencing respiratory depression. How soon can the nurse expect to see improvement in the client's respiratory function?

Within one to five minutes, an effect may be seen. Rationale: Onset of action is generally rapid and may be seen within one to five minutes. Additional doses may be required to achieve optimal effects. The other answers are incorrect because they are referring to a time later than onset of action, or refer to a conditional onset of action that is untrue.

When administering an opioid antagonist drug to a client, the primary goal of the therapy is to provide:

a return to normal respiratory rate, rhythm, and depth. Rationale: The primary reason for administering an opioid antagonist is because the client is experiencing respiratory depression. Therefore, the goal is to improve the client's respiratory rate, rhythm, and depth. None of the other options is part of the drug therapy.

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. Rationale: 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 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. Rationale: 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.

In the PACU the nurse must take into consideration which before giving pain medicine to the postoperative client?

continued pain relief and client's ability to breathe. Rationale: The PACU nurse frequently uses Narcan postoperatively. As the client awakes from the deep operative sleep, the nurse must balance the need for continued pain relief against the person's ability to breathe independently after the surgery. The others are not a concern of the PACU nurse.

As part of the ongoing assessment of a client during administration of an opioid antagonist, the nurse would monitor the client's blood pressure, pulse, and respiratory rate at which frequency until the client responds?

every 5 minutes Rationale: As part of the ongoing assessment during the administration of the opioid antagonist, the nurse monitors the client's blood pressure, pulse, and respiratory rate at frequent intervals, usually every 5 minutes, until the client responds. Any longer time will not be a true ongoing assessment in this circumstance, and critical changes can occur if not monitored more closely.

Naloxone will reverse the effects of which drugs? Select all that apply.

fentanyl codeine Rationale: Naloxone is an opioid antagonist, which means it will only reverse the effects of opioids like fentanyl and codeine. Lorazepam is a benzodiazepine, thus naloxone has no effect on it. Valproic acid is used in the treatment of seizures and is not an opioid. Warfarin is an anticoagulant used to prevent blood clots from forming.

A nurse should not administer an opioid antagonist to a client with which finding?

hypersensitivity to naloxone. Rationale: The use of opioid antagonists is contraindicated in those with a hypersensitivity to the opioid antagonists; therefore, a client with a hypersensitivity to naloxone should not be given the drug. Naloxone can be given to uncontrolled type 2 diabetics. Having a history of opioid or alcohol abuse does not have any effect on the use of naloxone.

Opioid naïve

no previous use or infrequent use of opioid medications

The nurse identifies which expected outcomes for a client who has been administered Narcan for respiratory depression? Select all that apply.

normal respiratory rate normal respiratory depth normal respiratory rhythm Rationale: Expected outcomes for the client with respiratory depression are an optimal response to therapy and support of client needs. This is essentially a return to normal respiratory rate, rhythm, and depth. Being free of pain and having a normal blood pressure are not outcomes for managing this client. If the client has a history of hypertension, then the BP will usually remain elevated. Being free from pain is not a outcome when managing respiratory depression.

Which client would the nurse identify as being opioid naive?

one who does not routinely take opioids. Rationale: Opioid-naive clients are defined as those who do not use opioids or infrequently use them. Those who routinely take and are physically or psychologically dependent on opioids are not considered opioid naive.

The client who does not use opioids regularly and suffers respiratory depression after given an opioid during a surgical procedure is described as which?

opioid naive. Rationale: The client who does not use opioids routinely and is given an opioid for acute pain relief or a surgical procedure is at most risk for respiratory depression after opioid administration. This client is described as opioid naive. The other terms are not terms that apply to these clients

Opioid antagonists may produce withdrawal symptoms in clients physically dependent on which substance?

opioids Rationale: Opioid antagonists may produce withdrawal symptoms in clients physically dependent on opioids. Naloxone has no effect on benzodiazepines, alcohol, or NSAIDs.

A new graduate nurse lists which of the following as uses for opioid antagonists? (Check all that apply.)

postoperative acute respiratory depression opioid adverse effects (reversal) suspected acute opioid overdosage Rationale: Opioid antagonists are used for the treatment of postoperative acute respiratory depression, opioid adverse effects (reversal), and suspected acute opioid overdosage.

After obtaining the history of a client who is prescribed opioid therapy, the nurse determines that the client is opioid naïve. The nurse would be especially alert for which effect after the client receives the prescribed opioid?

respiratory depression Rationale: Opioid-naive clients are mostly at risk for respiratory depression after opioid administration. First time opioid users do not experience diarrhea, hypertension, or physical dependence.

If a client begins to experience somnolence after receiving an opioid, the first action the nurse should take is:

rouse the client and coach the breathing pattern. Rationale: Sometimes the somnolence (drowsiness) and pain relief produced by the opioid will slow the client's breathing pattern. The nurse should first make an effort to rouse the client and coach his or her breathing pattern. Then, before administering an antagonist, the nurse should obtain the blood pressure, pulse, and respiratory rate and review the record for the drug suspected of causing the respiratory depression. The other actions would be done at a later time if warranted

Antagonist

substance that counteracts the action of something else

The nurse understands that when administering Narcan to a client for respiratory depression, the client will experience abrupt pain. This is because:

the opioid no longer works in the body. Rationale: When the antagonist drug is given to clients, they experience pain abruptly because the opioid no longer works in the body. The nurse should assess the pain level and begin to treat the pain again cautiously. It is not a psychological effect, nor does it cause pain at the IV site. The client may become more awake, but this is not the cause of the pain returning.

The nurse administering an opioid antagonist to a client who is physically dependent on the opioid should expect to see which?

withdrawal symptoms Rationale: Opioid antagonists may produce withdrawal symptoms in clients who are physically dependent on the opioid. A decrease in blood glucose level and drop in oxygen saturation are not attributed to these drugs. Respiratory depression is one use of the drug and not an adverse reaction to it.