A client has been receiving the same dose of IV opiate for 2 days to manage post-surgical pain. The client reports the drug is no longer controlling the pain. What does the nurse suspect?

Tolerance to the opiate medication is developing

There is likely a history of addiction

The client is opiate naive

Physical dependence

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Tolerance to the opiate medication is developing. This is the most likely explanation for why the client's pain is no longer being controlled by the same dose of medication. Tolerance is a physiological adaptation that occurs with repeated exposure to opioids, leading to a decrease in their effectiveness over time. This means that the client's body is becoming less responsive to the medication, and a higher dose is needed to achieve the same level of pain relief.
Choice B rationale:
There is likely a history of addiction. While it is possible that the client has a history of addiction, this is not the most likely explanation for why the medication is no longer controlling the pain. Addiction is a complex condition that is characterized by compulsive drug seeking and use, despite negative consequences. It is not simply a matter of tolerance developing.
Choice C rationale:
The client is opiate naive. This means that the client has not previously been exposed to opioids. While opiate-naive clients may be more sensitive to the effects of opioids, they are also more likely to experience side effects, such as nausea and vomiting. The fact that the client has been receiving the same dose of medication for 2 days without experiencing side effects suggests that they are not opiate naive.
Choice D rationale:
Physical dependence. Physical dependence is a state of adaptation that occurs with repeated exposure to opioids, leading to withdrawal symptoms if the medication is abruptly stopped. However, physical dependence does not necessarily mean that the medication is no longer effective in controlling pain.

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Correct Answer is A

Explanation

Rationale for Choice A:
A shift to the left in the white blood cell (WBC) count indicates an increased presence of immature neutrophils, known as bands. This is a hallmark sign of infection, as the body is rapidly producing and releasing these cells to fight off invading pathogens.
Prompt notification of the primary health care provider is crucial to initiate timely antibiotic therapy, if indicated. Early intervention with appropriate antibiotics can effectively combat the infection, prevent its progression, and potentially avert serious complications.
Delaying antibiotic treatment can allow the infection to worsen, potentially leading to sepsis, septic shock, or other life- threatening conditions.
Rationale for Choice B:
While informing the client about the significance of a shift to the left is important for education and understanding, it does not address the immediate need for medical intervention.
The priority action is to involve the primary health care provider for prompt assessment and potential initiation of antibiotic therapy.
Rationale for Choice C:
Documenting findings and continuing to monitor the client's condition is essential for ongoing assessment and evaluation, but it does not constitute a proactive intervention to address the underlying infection.
Documentation alone does not initiate treatment, and monitoring without intervention risks allowing the infection to progress.
Rationale for Choice D:
Protective isolation is not routinely indicated for clients with a shift to the left in their WBC count unless there is a specific concern for transmission of a highly contagious infection.
The decision to implement protective isolation measures would be based on the client's overall clinical presentation and potential infectious risks, as determined by the primary health care provider.

A. Massage the site with scented oils B. Apply warm compresses to the site C. Administer topical lidocaine to the site D. Administer prescribed oral pain medication

Correct Answer is B

Explanation

Choice A rationale:
Massaging the site with scented oils is not recommended for pain relief after removal of a peripheral vascular access device. There is no evidence to support the effectiveness of scented oils in this context.
Additionally, some scented oils can be irritating to the skin, which could potentially worsen the pain, redness, and swelling.
It's crucial to use products that are specifically designed for wound care and pain management, and to follow the healthcare provider's instructions.
Choice B rationale:
Applying warm compresses to the site is an effective and recommended intervention to alleviate pain, redness, and swelling after removal of a peripheral vascular access device.
Warm compresses have the following beneficial effects:
Vasodilation: They promote blood flow to the area, which helps to reduce inflammation and pain. Muscle relaxation: The warmth helps to relax tense muscles, further easing discomfort.
Pain relief: Warmth can directly inhibit pain signals, providing a soothing sensation.
Increased circulation: Improved blood flow can help to remove inflammatory substances and promote healing. It's important to use a clean, warm compress and to apply it for 15-20 minutes at a time, several times a day.
Choice C rationale:
Topical lidocaine is a local anesthetic that can temporarily numb the skin.
While it can be used for pain relief, it's not typically the first-line intervention for pain associated with removal of a peripheral vascular access device.
Warm compresses are often preferred as they provide a more natural and non-invasive approach to pain management.
Choice D rationale:
Oral pain medication may be necessary if warm compresses do not provide adequate pain relief.
However, it's important to follow the healthcare provider's instructions regarding the type and dosage of pain medication to use.
Over-the-counter pain relievers, such as acetaminophen or ibuprofen, may be sufficient in some cases. Stronger prescription pain medication may be needed for more severe pain.

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A client has been receiving the same dose of IV opiate for 2 days to manage post-surgical pain. The client reports the drug is no longer controlling the pain. What does the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?

Correct Answer is A

Explanation

A nurse is attending to a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. What action should the nurse take to alleviate the pain after removing the device?

Correct Answer is B

Explanation

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