Comfort, Anxiety, And Mobility Flashcards
The nurse is assessing a patient taking morphine sulfate. Which assessment requires immediate action?
Pinpoint pupils
Pinpoint pupils might be a sign of morphine overdose or toxicity. The nurse needs to act on this finding immediately. Decreased bowel sounds and constipation are expected. Nausea and delayed gastric emptying are expected side effects of morphine sulfate and do not require immediate action.
A patient is admitted for treatment of opioid addiction. Which priority intervention should the nurse implement?
Administer methadone.
Methadone is a synthetic opioid analgesic with gentler withdrawal symptoms and is the drug of choice for detoxification treatment. The patient’s blood pressure needs to be monitored more frequently than every 8 hours for a patient in withdrawal. The patient’s temperature is not a concern. Narcan is not administered to the patient in withdrawal from narcotic addiction.
A patient has been admitted after overdosing on acetaminophen. The nurse plans to monitor this patient for development of which complication related to the overdose?
Acute hepatic necrosis
Acetaminophen in large doses is extremely hepatotoxic. Patients with normal hepatic function should receive no more than 4000 mg/day. An overdosage of acetaminophen should not result in decreased urinary output, kidney stones, or metabolic alkalosis.
Which assessment is most important for the nurse to monitor in a patient receiving an opioid analgesic?
Respiratory rate
The most serious side effect of narcotic analgesics is respiratory depression.
A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse why she is receiving codeine when she is free of pain. What is the nurse’s best response?
“This medication will help decrease your coughing.”
Codeine provides both analgesic and antitussive therapeutic effects. It does not strengthen the immune system, increase lung volume, or help the patient expectorate sputum.
In monitoring a patient for adverse effects related to morphine sulfate, which is a priority assessment?
Assess for nausea and vomiting.
Morphine sulfate can cause nausea and vomiting by stimulating the vomiting center in the brain.
The nurse is preparing to administer an injection of morphine to a patient and notes a respiratory rate of 10 breaths/min. What is the nurse’s best action?
Notify the health care provider and delay drug administration.
Respiratory depression is a side effect of opioid analgesia. Therefore, since the patient’s respiratory rate is below normal, the nurse should withhold the morphine and notify the health care provider. The drug should not be given while the respiratory rate is this much low, and the health care provider should be notified of the change in the patient’s condition.
What should the nurse teach the patient to minimize gastrointestinal (GI) side effects of opioid analgesics for chronic pain?
Increase fluid and fiber in the diet.
Opioid analgesics decrease intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can prevent this. Eating foods high in lactobacilli and taking the medication on an empty stomach will not minimize GI side effects and may intensify them. Lomotil is used to treat diarrhea rather than the constipation that would result from use of narcotic analgesics.
What should the nurse teach the patient who is prescribed a fentanyl transdermal delivery system?
Change the patch every 72 hours.
The fentanyl transdermal delivery system is designed to slowly release analgesic over a 72-hour period. It should not be changed every time that pain recurs, every 24 hours, or once a week.
In developing a plan of care for a patient receiving morphine sulfate, which nursing diagnosis is a priority?
Impaired gas exchange related to respiratory depression
Using Maslow’s hierarchy of needs and the ABCs of prioritization, impaired gas exchange is a priority.
The nurse is teaching a patient with decreased hepatic function about taking pain relievers. What is the most important information to teach this patient?
Take no more than 2 grams of acetaminophen per day.
The patient with decreased hepatic function should decrease the dose of acetaminophen.
A patient who has been taking morphine for pain is assessed by the nurse. The patient’s respiratory rate is 7 per minute, and pupils are 1 mm and unreactive. What is the nurse’s immediate action?
Administer naloxone.
Morphine overdose can be indicated by unresponsive, pinpoint pupils and respiratory depression. Rescue breathing, calling anesthesia, or calling a code will not correct the underlying problem.
The patient is admitted with an acetaminophen overdose. In addition to monitoring liver function results, the nurse would anticipate administering which of the following?
Acetylcysteine
When acetaminophen toxicity occurs, acetylcysteine is the antidote, which reduces liver injury by converting toxic metabolites to a nontoxic form.
Which assessment finding in a patient taking NSAIDs requires immediate intervention?
Black, tarry stools
A major side effect of NSAID therapy is gastrointestinal (GI) distress with potential GI bleeding. Black, tarry stools are indicative of a GI bleed. Headaches, cough, and palpitations should not result from the use of NSAID medications.
Which intervention is most appropriate for a patient who needs treatment for acute postoperative pain?
Administer ketorolac IV every 4 hours PRN.
Ketorolac is the only NSAID that can be administered by injection (intramuscularly or intravenously) and is indicated for short-term use for severe to moderate pain. Acute postoperative pain cannot be effectively managed with oral medication.
A patient is to receive dopamine 5 mcg/kg/min. The patient weighs 176 pounds. An infusion of dopamine 400 mg in 500 mL of D5W is available. The nurse will infuse this drug at a rate of how many milliliters per hour. __ mL/h
The correct answer is: 30
The patient’s weight of 176 lb. is converted to kg by dividing by 2.2: 176 ÷ 2.2 = 80 kg. 5 mcg/kg × 80 kg = 400 mcg, or 0.4 mg/min. 0.4 mg/min ÷ 400 mg/500 mL = 0.5 mL/min; 0.5 mL/min × 60 min = 30 mL/h.
Which finding would indicate to the nurse that a medication has activated alpha1 receptors?
Increase in blood pressure
When alpha1 receptors are stimulated, the nurse will see increases in force of heart contraction; vasoconstriction increases blood pressure; mydriasis (dilation of pupils) occurs; secretion in salivary glands decreases; urinary bladder relaxation and urinary sphincter contraction increases.
Which finding would indicate to the nurse that a medication has activated beta2 receptors?
Hyperglycemia
When beta2 receptors are stimulated, the nurse will observe dilation of bronchioles; gastrointestinal and uterine relaxation; increases in blood glucose through glycogenolysis in the liver and increases in blood flow in skeletal muscles.
A patient with cardiac decompensation is receiving dobutamine as a continuous infusion. The patient’s blood pressure has increased from 100/80 mm Hg to 130/90 mm Hg. What is the nurse’s priority action?
Assess hourly blood pressure readings.
The major therapeutic effect of dobutamine is to increase cardiac output. Cardiac output is reflected in the patient’s heart rate, blood pressure, and urine output. An increase in blood pressure is the expected therapeutic effect.
The nurse assesses a patient receiving an adrenergic (sympathomimetic) agent. Which finding will be of most concern to the nurse?
Weak peripheral pulses and decreased heart rate.
Adrenergic agents stimulate the sympathetic nervous system, which increases heart rate (positive chronotropic effect), contractility (positive inotropic effect), and conductivity (positive dromotropic effect). The nurse would be most concerned that the pulses remain weak and heart rate decreased after receiving this drug, as the therapeutic effect is not being achieved.
The nurse assesses the peripheral intravenous infusion site of a patient receiving intravenous dopamine and suspects extravasation. What is the nurse’s initial action?
Stop the infusion.
The nurse’s first action is to stop the infusion, followed by infusing phentolamine into the area to counteract vasoconstrictive effects of the dopamine.
The nurse is caring for a patient diagnosed with heart failure and chronic obstructive pulmonary disease (COPD). The patient is ordered a nonselective beta blocker. What is the nurse’s initial intervention?
Call the health care provider to request a different medication.
Nonselective beta blockers are used to treat supraventricular dysrhythmias secondary to their negative chronotropic effects (decreasing heart rate). They may exacerbate heart failure and COPD. The patient could receive a selective beta blocker instead. The nurse should make the health care provider aware of the patient’s history of respiratory disease.
